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Biological 
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International 
Abstract of Surgery 



SUPPLEMENTARY TO 



Surgery, Gynecology and Obstetrics 



PUBLISHED IN COLLABORATION WITH 

JOURNAL DE CHIRURGIE, Paris 

ZENTRALBLATT FUER DIE GESAMTE CHIRURGIE UND IHRE 

GRENZGEBIETE, Berlin 

ZENTRALBLATT FUER DIE GESAMTE GYNAEKOLOGIE UND 

GEBURTSHILFE SOWIE DEREN GRENZGEBIETE, Berlin 



EDITORS 

FRANKLIN H. MARTIN, M.D., Chicago 

PROFESSOR AUGUST BIER, Berlin PAUL LECENE. M.D., Paris 

SIR BERKELEY MOYNIHAN, M.S., F.R.C.S., Leeds 



CAREY CULBERTSON, M.D., Abstract Editor 



Volume XXIII 
July-December, 191 6 






PUBLISHED BY 

THE SURGICAL PUBLISHING COMPANY OF CHICAGO 

30 NORTH MICHIGAN AVENUE. CHICAGO 

1916 



Copyright by 

THE SURGICAL PUBLISHING COMPANY 

OF CHICAGO 

1916 



I 

u 



INTERNATIONAL ABSTRACT OF SURGERY 
CONSULTING EDITORL\L STAFF 



m 



GENERAL SURGERY 



AMERICA: E. Wyllys Andrews Willard Bartlett Frederic A. Besley Arthur Dean Bevan J, F. 
BiNNiE George E, Brewer W. B. Brinsmade John Young Brown David Cheever H. R. Chislett Robert 
C. Coffey F, Gregory Connell Frederic J. Cotton George W. Crile W. R, Cubbins Harvey Cushino 
J. Chalmers DaCosta Charles Davison D. N, Eisendrath J. M. T. Finney Jacob Frank Charles H. 
Frazier Emanuel Friend William Fuller John H. Gibbon D. W. Graham W. W. Grant A. E. Halstead 
M. L. Harris A. P. Heineck William Hessert Thomas W. Huntington Jabez N. Jackson E. S. Judd 
C. E. Kahlke Arthur A. Law Robert G. Le Conte Dean D. Lewis Archibald Maclaren Edward Martin 
RtTDOLPH Matas Charles H, Mayo William J. Mayo John R. McDill Stuart McGuire Lewis S. McMurtry 
Willy Meyer James E. Moore Fred T. Murphy James M. Neff Edward H. Nichols A. J. Ochsner 
Charles H. Peck J. R. Pennington S. C. Plummer Charles A. Powers Joseph Ransohoff H.M. Richter 
Emmet Rixford H. A. Royster W. E. Schroeder Charles L. Scudder M. G. Seelig E. J. Senn 
John E. Summers James E. Thompson Herman Tuholske John W. Turner George Tully Vaughan 
John R. Wathen. CANADA: E. W. Archibald G. E. Armstrong H. A. Bruce I. H. Cameron 
Jasper Halpenny J. Alex Hutchinson Francts J Shepherd F. N. G. Starr T.D.Walker. ENGLAND: 
H. Brunton Angus Arthur E. Barker W. Watson Cheyne W. Sampson Handley W. Arbuthnot Lane 
G. H. Makins Robert Milne B. G. A. Moynihan Rushton Parker Harold J. Stiles Gordon Taylor. 
IRELAND: William Ireland de C. Wheeler. 



GYNECOLOGY AND OBSTETRICS 



AMERICA: Frank T. Andrews Brooke M. Anspach W. E. Ashton J. M. Baldy Channing W. Barrett 
Herman J. Boldt J. Wesley Bov£e LeRoy Broun Henry T. Byford John G. Clark Edwin B. Cragin 
Thomas S. Cullen Edward P. Davis Joseph B. De Lee Robert L. Dickinson W. A. Newman Dorland 
E. C. Dudley Hugo Ehrenfest C. S. Elder Palmer Findley Henry D. Fry George Gellhorn J. Riddle 
GoFFE Seth C. Gordon Barton C. Hirst Joseph T. Johnson Howard A. Kelly Albert F. A. King 
Florian Krug L. J. Ladinski H. F. Lewis Frank W. Lynch Walter P. Manton James W. Markoe 
E. E. Montgomery Henry P. Newman George H. Noble Charles E. Paddock Charles B. Penrose Reuben 
Peterson John O. Polak William M. Polk Charles B, Reed Edward Reynolds Emil Ries John A. 
Sampson F. F. Simpson Richard R. Smith William S. Stone H. M. Stowe William E. Studdiford 
Frederick J. Taussig Howard C. Taylor Hiram N. Vineberg W. F. B. Wakefield George G. Ward, Jr. 
William H. Wathen J. Whitridge Williams. CANADA: W. W. Chipman William Gardner F. W. Marlow 
K. C. McIlwraith B. P. Watson A. H. Wright. ENGLAND : Russell Andrews Thomas W. Eden 
W. E. FoTHERGiLL T. B. Hellier Thomas Wilson. SCOTLAND : William Fordyce J. M. Munroe Kerr. 
IRELAND : Henry Jellett Hastings Tweedy. AUSTRALIA : Ralph Worrall. SOUTH AFRICA : 
H. Temple Mursell. INDIA: Kedarnath Das. 



GENITO-URINARY SURGERY 



AMERICA: William L. Baum Wiluam T. Belfield Joseph L. Boehm L. W. Bremerman Hugh Cabot 
John R. Caulk Charles H. Chetwood John H. Cunningham Ramon Guiteras Franos R. Hagner 
Robert Herbst Edward L. Keyes, Jr. Gustav Kolischer F. Kreissel Bransford Lewis G. Frank 
Lydston Granville MacGowan L. E. Schmidt J. Bentley Squier B. A. Thomas William N. Wishard 
Hugh H. Young Joseph Zeisler. ENGLAND : J. W. Thomson Walker John G. Pardoe. INDIA : 
Mrigendralal Mitra. 



iv INTERNATIONAL ABSTRACT OF SURGERY 

CONSULTING EDITORIAL STAFF— Continued 

ORTHOPEDIC SURGERY 

AMERICA: E.C.Abbott Nathaniel Allison W. S. Baer Gwilym G. Davis Albert H. Freiberg 
Arthur J. Gillette Virgil P. Gibney Joel E, Goldthwait G. W. Irving Robert W. Lovett George B. 
Packard W. W. Plummer John L. Porter John Ridlon Edwin W. Ryerson Harry M. Sherman David 
Silver H. L. Taylor H. Augustus Wilson James K. Young. CANADA: A. Mackenzie Forbes Herbert 
P. H. Galloway Clarence L. Starr. ENGLAND : Robert Jones A. H. Tubby George A. Wright. 



RADIOLOGY 

AMERICA: Eugene W. Caldwell Russell D. Carman James T. Case L. Gregory Cole Preston M. 
Hickey Henry Hulst George C. Johnston Sidney Lange George E. Pfahler Hollis E. Potte*. 
CANADA : Samuel Cummings Alexander Howard Pirie. 



SURGERY OF THE EYE 

AMERICA: C. H. Beard E. V. L. Brown H. D. Bruns Vard H. Hulen Edward Jackson Francis Lane 
W. P. Marple William Campbell Posey Brown Pusey Robert L. Randolph John E. Weeks Cassius D. 
Wescott William H. Wilder Casey A. Wood Hiram Woods. ENGLAND: J. B. Lawford W.T.Holmes 
Spicer. SCOTLAND : George A. Berry A. Maitland Ramsey. 



SURGERY OF THE EAR 

AMERICA: Ewing W. Day Max A. Goldstein J. F. McKernon Norval H. Pierce S. MacCuen 
Smith. CANADA: H. S, Birkett. ENGLAND: A. H. Cheatle. SCOTLAND: A. Logan Turner. IRELAND: 
Robert H. Woods. 

SURGERY OF THE NOSE, THROAT, AND MOUTH 

AMERICA: Joseph C. Beck T. Melville Hardie Thomas J. Harris Chrisham R. Holmes E. Fletcher 
Ingals Chevalier Jackson John N. MacKinzie G. Hudson Makuen George Paull Marquis John Edwin 
Rhodes. AUSTRALIA: A. J. Brady A. L. Kenney. INDIA: F. O'KitiEALY. 



ABSTRACT EDITORIAL STAFF 
DEPARTMENT EDITORS 

DEAN D. LEWIS — General Surgery HOLLIS E. POTTER — Radiology 

CHARLES B. REED — Gynecology and FRANCIS LANE — Surgery of the Eye 

Obstetrics NORVAL H. PIERCE — Surgery of the Ear 

LOUIS E. SCHMIDT— Genito-Urinary Surgery T. MELVILLE HARDIE— Surgery of the Nose 
JOHN L. PORTER— Orthopedic Surgery and Throat 



INTERNATIONAL ABSTRACT OF SURGERY v 

ABSTRACT EDITORIAL STAFF— Continued 

GENERAL SURGERY 

AMERICA: Carroll W. Allen E. K. Armstrong Donald C. Balfour H. R. Basinger George E. 
Beilby. Walter M. Boothby Barney Brooks Walter H. Bxjhug Eugene Cary Otto Castle Phillips M. 
Chase James F. Churchill Isadore Cohn Karl Connell Lewis B. Crawford V. C. David Nathan S. 
Davis, III D. L. Despard A. Henry Dunn L. G. Dwan Frederick G. Dyas Albert Ehrenfried A. B. 
Eustace Ellis Fischel Isaac Gerber Herman B. Gessner Donald C. Gordon Torr Wagner Harmer 
James P. Henderson Charles Gordon Heyd Harold P. Kuhn LuaAN H. Landry Felix A. Larue 
Halsey B. Loder William Carpenter MacCarty Urban Maes B. F. McGrath R. W. McNealy Alfred 
H. Noehren Eugene J. O'Neill Matthew W. Pickard Frank W. Pinneo Eugene H. Pool H. A. Potts 
Martin B. Rehling E. C. Riebel Floyd Riley E. C. Robitshek M. J. Seifert O. R. Sevin J. H. Skiles 
Harry G. Sloan John Smythe Carl R. Steinke Lister H. Tuholske Henry J. Van den Berg W. M. 
Wilkinson Espy M. Williams Erwin P. Zeisler. ENGLAND: James E. Adams Percival Cole Arthur 
Edmonds I. H. Houghton Robert E. Kelly William Gilliatt B. C. Maybury Eric P. Gould T. B. Legg 
Feldc Rood E. G. Schlesinger B. Sangster Simonds Harold Upcott O.G.Williams. SCOTLAND: 
John Fraser A. P. Mitchell Henry Wade D. P. D. Wilkie. IRELAND: R. Atkinson Stoney. 



GYNECOLOGY AND OBSTETRICS 

AMERICA: S. W. Bandler A. C. Beck Daniel L. Borden D. H. Boyd Anna M. Braunwarth E. A. 
BuLLARD W. H. Cary Sidney A. Chalfant Edward L. Cornell. A. H. Curtis Carl.H. Davis F. C. Essel- 
BRUEGGE Lilian K. P. Farrar Howard G. Garwood Maurice J. Gelpi Luba R. Goldsmith C. D. Hauch 
N. Sproat Heaney T. Leacraft Hein D. S. Hillis John C. Hirst C. D. Holmes F. C. Irving Norman 
L. Knipe George W. Kosmak H. W. Kostmayer R. H. Kuhns Julius Lackner Herman Lober Rafiel 
LoRiNi Donald Macomber Harvey B. Matthews L. P. Milligan Arthur A. Morse Ross McPherson 
Albert E. Pagan George W. Partridge William D. Phillips Heliodor Schiller A. H. Schmitt Henry 
ScHMiTZ Edwaioj SCHUMANN Emil Schwarz J. M. Slemons Camile J. Stamm Arnold Sturmdorf George 
de Tarnowsky S. B. Tyron Marie L. White P. F. Williams R. E. Wobus. CANADA: James R. Goodall 
H.M. Little. ENGLAND: Harold Chapple Harold Clifford F. H. Lacey W. Fletcher Shaw Clifford 
White. SCOTLAND: H. Leith Murray J. H. Willett. 

GENITO-URINARY SURGERY 

A^IERICA: Charles E. Barnett J. D. Barney B. S. Barringer Horace Binney J. B. Carnett 
Theodore Drozdowitz J. S. Eisenstaedt H. A. Fowler F. E. Gardner Louis Gross Thomas C. 
Hollow AY H. G. Hamer Robert H. Ivy I. S. Koll H. A. Kraus Herman L. Kretschmeb Martin 
Krotoszyner Victor D. Lespinasse William E. Lower Francis M. McCallum Harvey A. Moore 
Stirling W. Moorhead A. Nelken C. O'Crowley Edward A. Oliver R. F. O'Neil H. D. Orr C. D. 
PiCKRELL H. W. Plaggemeyer H. J. PoLKEY Jaroslav Radda S. W. Schapira George G. Smith A. C. 
Stokes L. L. Ten Broeck G. J. Thomas H. W. E. Walther Carl Lewis Wheeler H. McClure Young. 
ENGLAND: J. Swift Joly Sidney G. Macdonald. IRELAND: Andrew Fullerton S. S. Pringle Adams 
A. McConnel. 

ORTHOPEDIC SURGERY 

AMERICA: Charles A. Andrews A. C. Bachmeyer George I. Baumann George E. Bennett Ralph S. 
Brojier Lloyd T. Brown C. Herman Bucholz C. C. Chatterton W. A. Clark Robert B. Cofield Alex 
R. CoLviN Arthur J. Davidson Frank D. Dickson F. J. Gaenslen M. S. Henderson Philip Hoffman 



vi INTERNATIONAL ABSTRACT OF SURGERY 

ABSTRACT EDITORIAL STAFF— Continued 

ORTHOPEDIC SURGERY — Continued 

C. M. Jacobs S. F. Jones F. C. Kidner F.W.Lamb Philip Lewin Paul B. Magnuson James R. Martin 
George J. McChesney H. W. Meyerding H. W. Orr Archer O'Reilly Robert G. Packard H. A. Pingree 
Robert O. Ritter J. W. Sever John J. Shaw Arthur Steindler Charles A. Stone Paul P. Swett 
H. B.Thomas James 0. Wallace James T. Watkins C. E. Wells DeForest P. Willard H. W. Wilcox. 
CANADA : D. Gordon ^Evans. ENGLAND : Howard Buck E. [Rock Carling Naughton Dunn 

E. Laming Evans W. H. Hey John Morley T. P. McMurray Charles Roberts G. D. Telford. 

RADIOLOGY 

AMERICA: David R. Bowen John G, Burke William Evans Isaac Gerber Amedee Granger G. W. 
Grier Adolph Hartung Arthur Holding Leopold Jaches Albert Miller Edward H. Skinner David C. 
Strauss Frances E. Turley J. D. Zulick. 

SURGERY OF THE EYE 

AMERICA: E. W. Alexander N. M. Brinkerhoff J. Sheldon Clark C. G. Darling T. J. Dimitry 
J. B. Ellis E. B. Fowler Lewis J. Goldbach Harry S. Gradle J. Milton Griscom D. Forest Harbridge 
Emory Hill Gustavus I. Hogue E. F. Krug G. Dvorak Theobald Walter W. Watson. ENGLAND: 
F.J.Cunningham M.L.Hepburn Foster Moore. SCOTLAND: John Pearson Arthur Hy. H. Sinclair 
Ramsey H. Traquair James A. Wilson. 

SURGERY OF THE EAR 

AMERICA : H. Beattie Brown J. R. Fletcher A. Spencer Kaufman Robert L. Loughren Otto 
M. Rott W. H. Theobald T. C. Winters. CANADA : H. W. Jamieson, ENGLAND : G. J. Jenkins. 
SCOTLAND: J. S. Eraser. IRELAND: T.O.Graham. 

SURGERY OF THE NOSE, THROAT, AND MOUTH 

AMERICA: George M. Coates M. N. Federspiel Carl Fischer R. Clyde Lynch Ellen J. Pat- 
terson. AUSTRALIA: V. Munro. INDIA: John T. Murphy. 



INDEX OF SUBJECT MATTER 



COLLECTIVE REVIEWS 

The Vermiform Appendix. W. Frank Fowler, M.D., Rochester, N.Y i 

Relation Between Gynecological and Neurological Conditions. Richard R. Smith, M.D., F.A.CS., Grand Rapids, 

Michigan 117 

Congenital Malformations of the Neck. George de Tarnowsky, M.D., F.A.C.S., Chicago. . 217 

The Surgery of Glaucoma. Emory Hill, A .B., M.D., Chicago 333 

Present Status of Round Ligament Shortening as a Surgical Cure in Uterine Displacement. Sidney A. C half ant, 

M.D., F.A.C.S., Pittsburgh. 433 



ABSTRACTS OF CURRENT LITERATURE 



ABDERHALDEN reaction, Quantitative test of, 78 
Abdomen, Use of fluoroscopeto avoid leaving gauze 
pads and sponges in, 127; Penetrating wounds of, 
242, 243, 244; Acute surgical, 245; Extraction from, 
of bullet encysted in epiploon after injury, 362; 
Chronic, and acute, 362; Wounds of, by war pro- 
jectiles, 363; Menstrual fistula of, 404; Value of 
pain, jaundice, and tumor mass in differential diag- 
nosis of diseases of right upper quadrant of, 470; 
Gimshot wounds of, in pregnant women, 507 

Abdominal, Perforations of various, organs, 139; Nerve 
supply of lower, wall as related to Pfannenstiel 
incision, 228; Symptom and complications of gunshot 
woimds of solid, viscera, 246; Care of, surgical cases, 
247; Sympathetic system in diagnosis of, diseases, 
400; Sheet rubber superior to gauze sponges in, 
operations, 535; Nerve-blocking as practical method of 
anaesthesia for, operations, 536; pain when associated 
with abnormal temperature an indication for cau- 
tion in use of purgatives, 549; Relation of ether 
pneumonia to pelvic and, surgery, 593 

Abdominal woimds. Gunshot, 30; in war surgery, 137; 
and their treatment, 138; Evolution of treatment of, 
in ambulance at front, 138; Treatment of penetrating, 
in ambulance, 363 

Abortion, Duties of medical practitioners in criminal, 68; 
Uncontrollable vomiting of pregnancy, 177; Accidents 
due to rupture or, of simultaneous tubal pregnancies, 
177 

Abscess, Cerebral, due to suppurative tonsillitis, 131; 
Retropharyngeal, discharging into left bronchus, 
196; of lung after tonsillectomy, 196; Conduction 
anaesthesia in brain, 234; Ischiorectal, from fish-bone, 
259; of kidney cortex and its relation to paraneph- 
ritic suppuration, 416; Lung, following tonsillectomy, 

Absorption of adrenalin after intratracheal injection, 489 

Accessory sinuses. Diseases of, of nose, 314; Diagnosis 
and treatment of inflammatory affections of nasal, 
427; Radiography in diagnosis of diseases of nasal, 428 

Accident insurance, Breaking of stitches and opening of 
wound not covered by, 170 

Acidosis, in surgerj', 275, 573; in normal subjects with 
incidental observations on action of alcohol as an 
antiketogenic agent, 385; Pregnancy toxaemia, in 
pregnancy, 504; complicating, 597; Routine treat- 
ment of operative, 535 



Acne vulgaris. Vaccine therapy and other treatment in 
and furunculosis, 481 

Actinomycosis cured with radixun, 580 

Acute, dilatation of the stomach complicating operations 
on extremities, 127; Chronic and, abdomen, 362 

Adenitis, Treatment of tuberculous, by roentgen rays, 389 

Adenocarcinoma of cerebellimi, 356 

Adenoids, Removal of tonsils and, in diphtheria carriers, 98 

Adenomata, Functional significance of mitochondria in 
toxic thyroid, 450 

Adenomyoma, of rectovaginal septmn, 405, 594 

Adhesions, Peritoneal, prevention with citrate solutions, 
31, 32; Intraperitoneal, 549; Time relations of gastric 
pains with reference to gastric, 249; Intestinal, 255 

Adnexa, Technique by which conservatism is made 
possible in diseases of, 174; Technique of new pro- 
cedure for subtotal abdominal hysterectomy in uterine 
fibroma or inflammation of, 296 

Adrenals, Gastric ulcer following removal of, 33; problem, 
284; Liberation of epinephrin from, by stimiilation of 
splanchnic nerves and by massage, 284 

Adrenalin, Absorption of, after intratracheal injection, 489 

Aerocele, Intracranial, 130 

After-treatment, Inunediate and, of railway injuries, 
228; of amputation stumps, 268; Simple, for perineal 
wounds, 301 

Agglutination, Further observations on, of bacteria in 
vivo, 579 

Albee operation. Experience with, for spondylitis tuber- 
culosis, 477 

Alcohol, Acidosis in normal subjects; action of, as an anti- 
ketogenic agent, 385 

Alkali reserve, Method for determination of, of blood- 
plasma, 482 

Alternatives to operation of colotomy, 463 

Ambard's constant, 86 

Ambulance, Working of clearing, 398 

Amputation, Functional status of, stumps in war, 148; 
Prevention and treatment of, 152; at base hospitals 
in France, 267; After-treatment of, stumps, 268; 
Flapless, 268; Partial, of foot for gunshot wounds, 375; 
of penis for carcinoma; conditions after operation, 422 

Anaemia, Blood-transfusion in treatment of severe post- 
haemorrhagic, and haemorrhagic diseases, 279; Treat- 
ment by splenectomy of splenomegaly with, associated 
with syphilis, 557; Metabolism studies before and 
after splenectomy in pernicious, 560 



Vll 



vin 



INTERNATIONAL ABSTRACT OF SURGERY 



Anaesthesia, Local, and analgesia, i8; and general, 19; 
Spinal, 19, 230, 446; Caudal, in genito-urinary sur- 
gery, 19; Analgesia and, in obstetrics, 81; Tonsil 
operation under, 98; Appendectomy under, 258; in 
otorhinology, 231; Method of facilitating infiltration 
349; Rectal, 349 

Anaesthesia, General, Use of warmed ether vapor for, 129; 
Shockless surgery with help of paravertebral, with 
scopolamine and narcophine, 231; Conduction, in 
brain abscess, 234; Intravenous injection of mag- 
nesium sulphate for, in animals, 386; in labor, 411; 
Scopolamine-morphine, in labor, 507; Nerve-blocking 
as practical method of, for abdominal operations, 536; 
Organic depression of nerve-cell produced by pro- 
longed ether, 578 

Anjesthetics, Inhibition of toxicity of, for nephropathic 
kidney, 128; Choice of, and general analgesia in 
surgery and in obstetrics, 307; Influence of, on 
temperature of body, 446; Handling of children with 
tuberculosis of spine while they are under influence 
of, 480; Nitrous oxide-oxygen the most dangerous, 536 

Anal, Genito-urinary symptoms arising from, rectal and 
colonic diseases, 93 

Analgesia, Anaesthesia and, 18; and anaesthesia in obstet- 
rics, 81; Obstetrical, by epidural injections of novo- 
caine, 411; Parto-, 413 

Analgesics, in parturition, 307; Choice of anaesthetic and 
general, in surgery and in obstetrics, 307; in parturi- 
tion, 411 

Analysis, Cytological, of shock, 578 

Anastomosis, End-results of entero-biliary, 37; Intradural 
nerve in poliomyelitic paralysis, 571 

Anatomy, and pathology of seminal vesicles, 90; and 
surgery of thyroid glands, 449; Pathologic, of immedi- 
ate lesions in penetrating cranial fractures due to 
projectiles, 538 

Anatomical, cause of frequency of hydrocephalus in 
childhood, 448; position of localized foreign bodies, 492 

Aneurisms, of war wounds, 56; Cirsoid, 57; Epicrises in 
wound, 57; Treatment of femoral, 162; Gunshot 
arteriovenous, in which sac was situated on side 
opposite the vein, 280; Arteriovenous, of axillary 
artery, 380; of dorsalis pedis artery, 280; Diagnosis, 
symptomatology, and therapy of dilatation, of de- 
scending thoracic aorta, 280; Choice of operation 
in cure of, of extremity, 281; Traumatic, 380; Treat- 
ment of accessible arterial, 484; Diagnosis of, of 
descending aorta, 576 

Angiitis obliterans, Presenile gangrene-thrombo-, 483 

Angiogenesis, Relation of, to ossification, 73 

Angioma of larynx, 517 

Angioneurotic oedejna. Visceral crises in, 245 

Angulation and flexure, Acute, of sigmoid, 463 

Ani, Prolapsus, in adults, 466; Pruritus, 555 

Ankylosis following gunshot injuries of joints, 270 

Ano, Observation on fissure in, 466 

Anomalous development. Giant ureteral calculus, of genito- 
urinary tract, 510 

Anorectal, fistula, 259; injuries, 465 

Anteflexion, Dysmenorrhoea with, and retrocession, 590 

Anterior poliomyelitis. Operative treatment for disa- 
bilities and deformities following, 477 

Anthrax, 164 

Antiseptic, Surgical and, values of h5T)ochlorous acid, 17; 
Hexamine as urinfiry, 189; Method of testing, for 
wounds with some results, 230; action of ether in 
peritoneal infections, 248; Method of action of 
certain, and procedures for determination of their 
therapeutic value, 348 

Antitoxin, Prophylactic use of tetanus, 282 



Aorta, Diagnosis, symptomatology, and therapy of 
dilatation aneurisms of descending thoracic, 280; 
Diagnosis of aneurisms of descending, 576 

Aperiosteal stump and its care, 476 

Apparatus, Resuscitation, 537 

Appendix, Cystic dilatation of vermiform, 143; Roentgen 
examination of, 256; Fibroid degeneration of, 256; 
Pathological diagnosis of diseases of, 459; Treatment 
of retrocaecal, 462 

Appendectomy under local anaesthesia, 258 

Appendicitis, 368; Acute, 35; Urticaria and pseudo-, 67; 
Pseudo-, 552; Salpingitis secondary to, 74; Diagnosis 
of, in childhood, 143; Neglected, high mortality; 
diagnostic and therapeutic responsibility, 257; Time 
for operating in acute, and gall-bladder disease, 258; 
of extra-appendicular origin, 367; Prevention of faecal 
fistula in suppurative, 368; Treatment of suppurative, 
462; Results of treatment of acute, 368; False, in 
pregnancy, 410; Gestaton complicated by, 597; Mor- 
phine as early diagnostic element in acute, 461; Leu- 
cocyte count of, 461; Radiodiagnosis of, 552 

Application, Practical, of blood-pressure findings, 160 

Arch of foot. Painful anterior, operation for relief by 
raising arch, 269 

Arrested development of carpus and tarsus, 263 

Arsenic, Lethal dose of, for splenectomized mice, 580 

Artery, Aneurism of dorsalis pedis, 280 

Arteries, Embolism in, 575; Fractures of, 575 

Arteria meningea media. Intracranial haemorrhage due 
to traumatic rupture of, 22 

Arterial, Treatment of accessible, aneurisms, 484 

Arthritis, Retarded ossification as etiologic factor in 
traumatic, and epiphysitis, 40; Treatment of puru- 
lent, of knee by arthrostomy or marsupialization of 
synovial sac, 40; R61e of visceroptosis in, deformans, 
14s; Neck resection in secondary period of traumatic, 
357; Osteo-, 472; Treatment of traumatic, of knee, 567 

Arthritis: See also Joints 

Arthrodesis, Subastragalar, in lateral deformity of paralytic 
feet, 153, 478 

Arthroplasty of interphalangeal joints, 265 

Articular gunshot wounds, 563 

Ascites, Chylous, and chylothorax due to carcinoma of 
stomach, 454; Chylothorax, chylous, and lymphosar- 
coma, 454 

Astragalus, Fracture dislocation of, 372 

Astragalectomy; Result of, in infantile paralysis, 153 

Atresia, Congenital, of duodenum treated by operation, 
365; Complete congenital, of ileum, 458; Late con- 
servative caesarean operation with vertex fu'esen- 
tation for cicatricial, of vagina, 504 

Aural complications of influenza, 94 

Auscultation in diagnosis of vascular injuries accompany- 
ing gunshot wounds, 281 

Autoplasty, Venous, of traumatized urethra, 191 

Axillary artery. Arteriovenous aneurism of, 380 

Axis, Fracture of odontoid process of, 156 

BACCELLI'S method. Malignant pustule treated by, 

378 .... 

Bacillus pyocyaneus, Chronic general infection with, 58 
Bacillaemia, Tubercular, a clinico-experimental study, 388 
Back, Surgical aspects of painful, 272; Injuries of lower, 569 
Backache, Chronic, 156; from viewpoint of orthopedist, 480 
Backward, Treatment of, displacements of uterus, 500 
Bacteria, Demonstrating, in urine by centrifuge; relative 
value of examinations by culture or stained sediment, 
84; associated with certain types of abnormal l3anph- 
glands, 162; of gangrenous wounds, 283; Agglutina- 
tion of, in vivo, 579 



INDEX TO SUBJECT MATTER 



IX 



Bactericidal, Reactions between bacteria and animal 
tissues under conditions of artificial cultivation, 
action in tissue cultures, 163; Nature of, property of 
vaginal secretion, 592 

Bacteriologic, and experimental studies on gastric ulcer, 
486; study of causes of some stillbirths, 509 

Bacteriology, and experimental production of ovaritis, 
300; of nasal sinus disease, 516 

Basal metabolism in disease and its importance in 
clinical medicine, 573 

Beck-Pierce, Tonsil enucleations with, tonsillectome, 431 

Beclard and PirogofI, Ligature of lingual artery in triangles 
of, 197 

Benign growths, Malignant transformation of, 465 

Bergonie electrovibrator. Extraction of projectile from 
brain with use of, 131 

Bile-duct, Pressure of bile secretion during chronic obstruc- 
tion of common, 144; End-to-end suture of, 371; 
Congenital obliteration of, diagnosis and suggestions 
for treatment, 469 

Biliary passages. Surgery of gall-bladder and, 556 

Birth, Injuries to infant produced at, 82; Obstetrical or 
brachial, palsy, 509; Posterior dislocation of lower 
humeral epiphysis as, injury, 604; Beginnings of, 
control movement, 605 

Bismuth paste. Unusual faecal and genito-urinary cases 
treated by, 514; in chronic suppurative sinuses and 
empyema; incorrect technique in its application, 545 

Bladder, Makka's operation for ectopia of, 89; Cauteriza- 
tion and fulguration of, tumors, 89; Vesical fistula 
due to permanent foreign body in, 189; Extraction 
of bullets from, by natural route, 419; Foreign bodies 
in, resulting from gunshot wounds, 420; (Edema 
bullosxun of, 189; Fatal rupture of, during puerperium, 
305; Rupture of, associated with fracture of pelvis, 
512; Treatment of gunshot wounds in, 420; Manual 
expression of, in spinal injury, 421; Herniae of urinary, 
512; Treatment of, injuries by war projectiles, 610; 
Injuries of, and urethra in war, 609 

Blood, Association of spleen with liver and relation to 
certain conditions of, 38; and blood-vessels in hemo- 
philia and other haemorrhagic diseases, 53; Pro- 
thrombin and antithrombin factors in coagulation of, 
161; Disappearance of dextrose from, after intra- 
venous injection, 277; Testing donors for transfusion 
of, 279; Behavior of pancreatic ferments in, after 
ligature of pancreatic ducts, 286; Importance of 
lymphocytosis of, 378; Non-protein nitrogenous 
constituents of, and phenolsulphonephthalein test 
in children, 483; ferments in pregnancy, 506; Lipoid 
content of maternal and foetal, 508; Value of determi- 
nation of cholesterol content of, in diagnosis of 
cholelithiasis, 556 

Blood: See also Embolism, Transfusion, Thrombosis, 
Haemorrhage 

Blood-cells, Preservation of living red, in vitro, 52, 56 

Blood-plasma, Method for determination of alkali reserve 
of, 482 

Blood-pressure, Systolic, in pregnancy, 80; in dysthy- 
roidism, 134; Practical application of, findings, 160; 
during operations, 574 

Blood-transfusion, 279, 379; Reactions following, by 
syringe cannula system, 55; Indications for, 278; in 
treatment of severe post-haemorrhagic anaemia and 
haemorrhagic diseases, 279; Direct, with Kimp ton- 
Brown tubes, 280; in haemorrhage of newborn, 604 

Blood-vessels, Injuries of large, in war, 57; Reactions of, 
to certain chemicals, 488 

Blue sclerotics; their relation to multiple fractures in 
childhood, 472 



Bone, repair, 265; General heliotherapy in treatment of, 
and joint affections, 265; Use and limitations of 
stereoscopic radiograms in diagnosis of injury to, 
after-treatment of fractures, 287; Regeneration of 
long, following infection, 472; Treatment of abscesses 
in tuberculous disease of joints and, 475; Value of 
roentgenology in treatment of, and joint tuberculosis, 
581; Osteoperiostic grafts takep from tibia to serve 
in reconstruction of, or in repair of loss of osseous 
substance, 476; Regeneration of, 561 

Bone: See also Fractures, Graft, Transplantation 

Bone-graft, Pott's disease treated by, 44; for spinal con- 
ditions, 47; Autogenous, pin in treatment of painful 
flat-foot and paralytic valgus, 266 

Bone-graft: See also Transplantation 

Bone-peg, Heterogenous, 266 

Bone-plate, Cranioplasty; metallic, cartilaginous or^by, 

131 

Bone-splints, Autogenous, in fractures and tuberculous 
spines, 568 

Bone-transplantation, in nose deformities, 21; in ununited 
fractures of shaft of humerus, 264, 5(58; Important 
points in, 476; and some uses of bone-graft, 568; 
Treatment of caries of spine by, 570 

Bony union in intracapsular fractures of hip-joint, 146 

Bowel, Simple method of giving solutions by, 229 

Brachial plexus. Operative treatment of, paralysis, 157 

Brachial birth palsy, Obstetrical or, 509 

Brain, Extraction of projectile from, with Bergonie elec- 
trovibrator, 131; Movements of foreign bodies in, 
448J Conduction anaesthesia in, abscess, 234; abscess 
from chronic suppuration of frontal sinus, 615; 
Diagnosis and treatment of, injuries in adults, 355; 
Tumors of hypothalamic region of middle, 355; 
Teratomata of, 540; Process of cicatrization of open 
wounds of, 541 

Branchiogenic carcinoma, 541 

Breast, Tuberculosis of, 358; Anatomic study of lym- 
phatics of, from viewpoint of lymphatic extension of 
cancer, 542 

Breast, Cancer of, 239, 358; Early diagnosis of, 450 

Breast, Carcinoma of. Vertebral metastatic primary, 376; 
Relation between chronic mastitis and, 451 

Broad ligament, Infolding and peritonealizing stitch with 
application of same to, and gall-bladder, 346 

Bronchus, Paper clip in, seventeen years removed by 
superior bronchoscopy, 195; Retropharyngeal abscess 
discharging into left, 196; Carcinoma of oesphagus 
perforating into right, 453; Endothelioma of right, 
removed by peroral bronchoscopy, 547 

Bronchi, Removal of foreign bodies from oesphagus and, 
with description of new instruments, 242 

Bronchiectasis, Therapeutics of chronic non- tuberculous 
suppurative, 546; and bronchiectatic symptoms due 
to foreign bodies, 547 

Bronchoscopy, Paper clip in bronchus seventeen years 
removed by superior, 195 

Bubo, Cure of suppurated chancrous, by filiform drainage, 

275 

Buccal mucosa, Melanosarcoma of, 517 

Bullet, New method of, extraction, 228; lesions of cauda 
equina, 270; Removal of, and metallic foreign bodies, 
289; Finding of position of retained, 391; Extraction 
of free, from left pleura after establishment of artificial 
pneumothorax, 452 

Bunions, Plasterers' corns and, 145 

Burden of proof in actions for negligence, 495 

Burns, Treatment of, 159; Gas, 384 

Bursitis, Deposit in supraspinatus muscle simulating 
subacromial, 41 



INTERNATIONAL ABSTRACT OF SURGERY 



CACHEXIA of hypophysary origin, 378 
Caesarean section, 407; in Pitman's cottage, 79; 
Indications for high incision in, 79; Delivery by 
natural passages following, 178; by modified Davis 
operation, 303; high forceps; pituitary extract, 303; 
Transperitoneal suprasymphyseal, on account of 
scariform growth in vagina, 304; performed with 
pocket knife after death of mother resulting in 
normal and living child, 505; Segmental, 408; Foetal 
dystocia and, 410; Late conservative, with vertex 
presentation for cicatricial atresia of vagina, 504; 
Postmortem, 505; Rupture of scar of previous, 596 

Calcareous degeneration of prostate gland, 423 

Calcification, Relation of angiogenesis to ossification based 
on study of, and ossification of ovary, 73 

Calculus, of Wharton's duct, 353; Diagnosis of ureteral, 
419; Giant ureteral, anomalous development of 
genito-urinary tract, 510 

Calculi, in submaxillary gland and Wharton's duct, 21; 
Problems in X-ray diagnosis of urinary, 89; of vesi- 
coprostatic region in old prostatics, 423; Unilateral 
haematuria associated with fibrosis and multiple 
microscopic, of renal papillae, 510; Ureteral, 607 

Cancer, Aids in diagnosis of surgical conditions of stomach 
with especial reference to characteristic X-ray 
appearance of syphilitic hour-glass in contrast to 
simple ulcer and, 32; Radical operation for, of rectum 
and rectosigmoid, 36; Etiology and prophylaxis of, 
50; Pathological aspects of some problems of experi- 
mental research, 60; Roentgen treatment of deep 
seated, 62; Unrecognized syphilitic lesions surgically 
operated as, or as local tuberculosis, 67; subjected to 
surgical ionization, 158; Tissue cultures in investi- 
gation of, 273; Effects of, tissue and normal epithelium 
on vitality of protozoa, 273; Intra-ocular, sarcoma 
of choroid, 312; Use of heat in control of inoperable, 
498; of mouth and tongue with reference to metastases 
in neck, 517; Diagnosis of, of rectum, 554; as non- 
surgical disease, 571; Superheated steam in treatment 
of superficial, 572; Therapeutic value of radium in 
pelvic, 580 

Cancer of breast, 239, 358; Hypophyseal disorder in, and 
relation to diabetes insipidus, 135; Early diagnosis of, 
450; Anatomic study of lymphatics of breast from 
viewpoint of Ijonphatic, 542 

Cancer of cervix. Primary and end-resiilts in inoperable, 
treated by cautery method, 173; with especial ref- 
ence to combination method of treatment, 498 

Cancer of stomach, Etiologic relationship existing between 
gastric ulcer and, 140; Serious oesophagic spasms in, 
362; Diagnosis of, 551 

Cancer of uterus, 588; Prophylaxis of, 173 

Cancer: See also Tumor, Carcinoma, Sarcoma 

Carbolic injections, Mental symptoms complicating acute 
tetanus during treatment by, 282 

Carcinoma, of thyroid in fish, 237; Gelatinous, of peri- 
toneum, 248; Adeno-, of cerebellum, 356; Complete 
removal of intestinum rectmn and colon pelvinum 
for, 259; Primary, of urethra; retention of urine from 
obstruction with restoration of function by radium, 
421; Amputation of penis for, 422; of oesophagus 
perforating into right bronchus, 453; Branchiogenic, 
541; of colon causing intestinal obstruction, 554 

Carcinoma of breast, Vertebral metastatic, 376; Relation 
between chronic mastitis and, 451; Acute, 451 

Carcinoma of stomach. Occult. bleeding in ulcus ventriculi 
and, 364; Multiple acute gastric ulcers after using 
Percy's cold iron for inoperable, 365; Chylous ascites 
and chylothorax due to, 454 

Carcinoma of uterus, Heat as method of treatment in 



inoperable, 69; Roentgen treatment of, 174; treated 
according to Percy method, 588 

Carcinomata, of nasopharynx, 96; Influence of tethelin 
and other alcohol-soluble extractives from anterior 
lobe of pituitary body upon growth of, in rats, 385 

Cardiac, Three juxta-, projectiles extracted by three 
routes and different procedures, 361 

Caries of spine. Treatment of, by bone-transplantation, 570 

Carotid body. Tumors of, 25 

Carpus, Arrested development of, and tarsus, 263 

Carrel, Treatment of wounds by method of, 397; Results 
obtained from employing, method in war surgery, 494 

Cartilages, Treatment of unstable, of knee-joint, 567 

Cartilaginous, Repair of losses of frontal substance by 
means of, transplants, 22; Cranioplasty by, flap, 22; 
Multiple, exostoses, 39; Cranioplasty, metallic, or 
by bone-plate, 131; Miiltiple, exostoses, 472 

Cataract, Suture of cornea in, operation, 193; Newer 
principles in dealing with uncomplicated, 612 

Cataract: See also Eye, Glaucoma 

Catgut, Toluol as a storing fluid for, 128; Manufacture of, 
348 

Cauda equina. Bullet lesion of, 270 

Caudal anaesthesia in genito-urinary surgery, 19 

Causes and treatment of Perthe's disease, 561 

Cautery, Galvano-, operation for lower turbinate, 97; 
Primary and end-results in inoperable cancer of 
cervix treated by, method, 173 

Cauterization and fulguration of bladder tumors, 89 

Cava inferiore. Projectile in right lobe of heart after 
traversing, 453 

Celluloid, Surgical uses of, 231 

Cerebellar, Localization of, tumors, 24; Semicircular 
apparatus of ear and, localization as diagnostic key to 
intracranial conditions, 194; localization in light of 
recent research, 234; Localization of, tumors, 355 

Cerebellar: See also Brain 

Cerebellum, Glioma of, with metastases, 24; Adenocar- 
cinoma of, 356 

Cerebral, abscess due to suppurative tonsilitis, 131; nerve 
disturbances in exophthalmic goiter, 133; Cranial 
and cranio-, wounds, 354; Grave accidents of late 
appearance in cranio-, wounds of war, 354; Patho- 
genesis and treatment of precocious, persistent, 
hernia, 540; fat embolism with reference to delirium 
and coma, 576 

Cerebrospinal fluid, Value of various diagnostic methods 
for, 169 

Cervix, Lacerated, 69; Primary and end-results in inopera- 
ble cancer of, treated by cautery method, 173; 
Operating during puerperiima for cure of old lacera- 
tions of, and perineum, 406; Cancer of, uteri with 
reference to combination method of treatment, 498; 
Unilateral polypiform oedematous elongation of 
uterine, 499 

Cervical, ribs, 132; spondylitis of doubtful nature, 155; 
Sarcoma of nose with metastases in, glands and in 
brain, 613 

Chancrous, Cure of suppurated, bubo by filiform drainage, 

275 

Cheek defects, Plastics of penetrating, due to gunshot 
injuries, 232 

Chemical, study of tumors, 378; Reactions of blood- 
vessels to certain, 488; Use of artificial, light in 
lupus vulgaris, 572 

Chest, Wounds of, in warfare, 27; Radiography of, in 
children, 166; Gunshot wounds of, 239; Accurate 
method of localization of foreign bodies in, and their 
removal, 288; Clinical, cytological, and therapeutical 
study of wounds of, in ambulance at front, 542 



INDEX TO SUBJECT MATTER 



XI 



Childbirth, painless, 179 

Chloroform, Sudden death in, narcosis, 349; Dangers of, 

narcosis, 446; Use of, in first stages of labor, 6co 
Cholecystectomy, and cholecystostomy, 37; Retrograde, 

for chronic cholecystitis, 143; versus dholecystostomy, 

SS6 
Cholecystectomy: See also Gall-bladder 
Cholecystitis, Retrograde cholecystectomy for chronic, 

143; Postoperative treatment of peptic ulcer and, 

251; changes produced by removal of gall-bladder, 468 
Cholecystostomy, Cholecystectomy and, 37; versus 

cholecystectomy, 556 
Cholelithiasis, Uncertainties of understanding anent, 37; 

Value of determination of cholesterol content of 

blood in diagnosis of, 556 
Cholesteatoma, Extensive, following Luc-Caldwell and 

Killian operation simulating sarcoma, 616 
Cholesterol content, Value of determination of, of blood 

in diagnosis of cholelithiasis, 556 
Choroid, Intra-ocular cancer; sarcoma of, 312 
Chronic, Phrenicotomy in treatment of some, diseases of 

lung, 360; abdomen and acute abdomen, 362 
Chylothorax, 544; chylous ascites, and lymphosarcoma, 

454; Chylous ascites and, due to carcinoma of stomach, 

.454 

Cicatrix, Inclusion of radial nerve in, total radial paral)^; 
liberation of nerve; reappearance of motion and 
sensation, 49; Repair of breach of trapezius and 
splenius with, adhering to cervical vertebrae, 374 

Cicatrization, Process of, of open wounds of brain, 541 

Ciliary arteries, Travunatic rupture of, 312 

Circulation, Reversal of, in lower extremity, 163; Clinical 
relations of gravity, posture, and, 293 

Cirsoid aneurism, 57 

Citrate solutions, Peritoneal adhesions; prevention with, 
31,32 

Classification of tiunors, 51 

Clavicle, Old dislocation of, 147 

Clinical, Pyloric exclusion an experimental and, study, 
142; lesions of hypophysis, 449; Basal metabolism in 
disease and their importance in, medicine, 573 

Club-foot, Treatment of, 153; Congenital, 269 

Coagulation, massive and xanthochromie occurring in 
tuberculosis of cervical spine, 156; Prothrombin and 
antithrombin factors in, of blood, 161 

Colic, Pancreatic stone, 38 

Collargol injections in small doses, 52 

Colles' fracture, 473 

Colon, Polyposis of, 143; Complete removal of intestinimi 
rectiun and, pelvimmi for carcinoma, 259; Carcinoma 
of, causing intestinal obstruction, 554 

Colonic, Anatomy, physiology and pathology of large in- 
testine with observations on radical operation for, 
tumors, 553; Experimental, stasis, 462 

Colotomy, Alternatives to operation of, 463 

Combination method. Cancer of cervix uteri with especial 
reference to, of treatment, 498 

Complications, Aural, of influenza, 94; of acute gonorrhoea 
in male, 192; Tetanus; a surgical, in present war, 282; 
Management of, of pregnancy, 598 

Complicating convalescence. Prevention and treatment of 
some obscure conditions, after gastro-enterostomy, 229 

Compression, Sinus thrombosis in, 130; Treatment of 
naevus flammeus and allied conditions by filtered 
ultraviolet rays employing, method of application, 491 

Concretions of spleen, 144 

Congenital, bilateral elevation of scapula, 46; Large, 
hydronephrosis in infant, 85; elevation of scapula, 
147; Etiology of, absence of parts, 154; cystic kidneys, 
186; Gastric volvulus in hour-glass stomach of, mal- 



formation, 249; club-foot, 269; anterior curvature 
of spine, 270; atresia of duodenum treated by opera- 
tion, 365; stricture of urethra, 421; Necessity for 
early diagnosis and continuous treatment in, syphilis, 
426; stenosis of duodenum in an adult, 456; Complete 
atresia of ileum, 458; obliteration of bile-ducts; 
diagnosis and suggestions for treatment, 469 

Conjunctival flap. Operative treatment of partial staphy- 
loma of cornea and fistula of cornea with, 612 

Conjunctivitis, Treatment of gonococcic, by autogonococ- 
cic serum, 94 

Conservatism, Technique by which, is made possible in 
diseases of adnexa, 174 

Conservative, Plea for, treatment of fractures, 147 

Consulting, Experiences of, surgeon, 495 

Contents of ovarian cysts, 502 

Cord, Anatomo-clinical study of total section of spinal, 47 

Cornea, Suture of, in cataract operation, 193; Operative 
treatment of partial staphyloma of, and fistula of 
cornea with conjunctival flap, 612 

Corneal, Rosacea keratitis and other forms of marginal 
keratitis, neuropathic in origin; treatment by peri- 
neurotomy, 94 

Corns, Plasterers', and bunions, 145 

Craniimi, Gunshot wounds of, 232 

Cranial, Intra-, haemorrhage due to traimiatic rupture of 
arteria meningea media, 22; Acute mastoiditis with 
imusual symptoms indicative of intra-, involvement; 
operation; recovery, 94; Intra-, aerocele, 130; Wounds 
in war surgery, 353; and craniocerebral woimds, 354; 
Pathologic anatomy of immediate lesions in pene- 
trating, fractures due to projectiles, 538; Wounds by 
war projectiles at front, 538; Treatment of, wounds 
at front, 539; Treatment of, wounds by war pro- 
jectiles, 539 

Craniocerebral, Grave accidents of late appearance in, 
wounds of war, 354; Operations for, wounds of 
modem warfare, 448 

Craniopharyngeal duct tmnors, 233 

Cranioplasty, by cartilaginous flap, 22; Metallic, cartilagi- 
nous or by bone-plate, 131 

Criminal abortion. Duties of medical practitioners in, 68 

Crises, Visceral, in angioneurotic cedema, 245 

Cnu-al hernias. Treatment of large, by pediculated 
adipose graft, 364 

Crying, Intra-uterine, 508 

Ciiltures, Tissue, in investigation of cancer, 273 

Ciuvature, Congenital anterior, of spine, 270 

Curved lines of suction, 604 

Cysts, Infection of ovarian dermoid, with tjqjhoid bacillus, 
74; Infra-epiglottal, 195; Congenital and fistulae of 
neck, 350; Contents of ovarian, 502; Labor obstructed 
by ovarian, 599 

Cystectomy, Total, one and a half years after operation, 
421 

Cystic, dilatation of vermiform appendix, 143; hygroma in 
infant, 185; Congenital, kidnej^, 186 

Cystocele, Etiology of uterine prolapse and, 500 

Cystography, Use of oxygen in, with preliminary report 
on use of oxygen in pyelography, 511 

Cytological analysis of shock, 578 

DACRYOCYSTITIS, Digital compression of lachrymal 
sac in, of newborn, 312 
Davis operation, Caesarean section by modified, 303 
Death, Sudden, in chloroform narcosis, 349; Caesarean 
section performed with a pocket knife after, of 
mother resulting in normal and living child, 505 
Deaths attributable to intranasal operations and other 
instrumentation, 97 



xu 



INTERNATIONAL ABSTRACT OF SURGERY 



Decidua, Histochemical research regarding the function 
of the, 306 

Deformities, of jaws resulting from operation or injury, 
21; due to infantile paralysis; operative treatment, 
45 ; of feet, 46; Operation for correction of, due to 
obstetrical paralysis, 49; Subastragalar arthrodesis 
in lateral, of paralytic feet, 153; Influence of os 
calcis on production and correction of valgus, of 
foot, 265; External genital, due to retardation in 
morphologic evolution, 301; Operative treatment for 
disabilities and, following anterior poliomyelitis, 477; 
Subastragalar arthorodesis in lateral, of paralytic 
feet, 478; Soldier's foot and treatment of common, of 
foot, 479 

Degeneration, Fibroid, of appendix, 256 

Delayed tetanus, 58 

Delbet, Study of pus in war surgery, by pyoculture 
method of, 493 

Delirium and coma, Cerebral fat embolism with reference 
to, 576 

Delivery by natural passages following caesarean section, 
178 

Dental, Roentgen ray in, practice, 431 

Dermatolysis and molluscum fibrosum with congenital 
morbus cordis and kyphosis, 275 

Dermoid, Infection of ovarian cyst with tj^hoid bacillus, 

Detachment, Haemorrhage associated with partial and 
complete, of normally implanted placenta, 304 

Devascularized, Treatment of, intestine, 367 

Dextrose, Disappearance of, from blood after intravenous 
injection, 277 

Diabetes insipidus. Hypophyseal disorder in mammary 
cancer and its relation to, 135 

Diabetes and prostatectomy, 424 

Diagnosis, of appendicitis in childhood, 143; Pathological, 
of diseases of appendix, 459; Appendicitis; its radio-, 
552; Practical methods in, 169; and treatment of 
brain injuries in adults, 355; Sympathetic system in, 
of abdominal diseases, 400; of cancer of stomach, 551; 
in gynecology, 404; Early, of cancer of breast, 450; 
Early, of intussusception in children under three 
years of age, 457; Duodenal tube as factor in, and 
treatment of gall-bladder disease, 466; Congenital 
obliteration of bile-ducts, and suggestions for treat- 
ment, 469; Corroborative, of mastoiditis by means 
of X-ray, 515; and treatment of trifacial neuralgia, 
537; Sarcoma of scapula; histological, made by study 
of blood aspirated from pulsating portion of tumor, 
542; of cancer of rectum, 554; of internal secretory 
disorders, 573; of aneurisms of descending aorta, 576; 
of pelvic troubles, 593; Urinary, of pregnancy, 601; 
of certain surgical lesions of kidneys, 606; of renal 
and ureteral calculi, 608; Pyelo-ureterography as 
aid in, of obscure surgical conditions of kidney and 
ureter, 608 

Diagnostic, Value of various, methods for cerebrospinal 
fluid, 169; Study plan for, team acting as laboratory 
for profession, 399; Morphine as an early, element in 
certain forms of acute appendicitis, 461; Intraperi- 
toneal inoculation of animals its, value in orthopedic 
surgery, 477 

Diaphragm, Eventration of, with report of right-sided 
eventration, 32 

Diaphysary, Treatment of, gunshot injuries in ambulance 
at the front, 561 

Differential diagnosis. Value of pain, jaundice, and tumor 
mass in, of diseases of right upper quadrant of abdo- 
men, 470 

Digestion, Management of surgical disorders of, 255 



Digestive tube, Spontaneous rupture of, 550 

Dilatation, Cystic, of vermiform appendix, 143; Adjust- 
ment of intra-uterine stem versus, to overcome 
stenosis of cervical canal, 173 

Dilatation aneurisms. Diagnosis, symptomatology, and 
therapy of, of descending thoracic aorta, 280 

Diphtheria, Prolonged use of tubes following, 357 

Diphtheria carriers. Removal of tonsils and adenoids in, 98 

Disabilities, Causes of prolonged, from fractures, 264; 
Surgical, of troops in training, 398; Operative treat- 
ment for, and deformities following anterior poliomye- 
litis, 477 

Diseases, Treatment of, of stomach, 34 

Disinfection, Results obtained by early and systematic 
of war wounds, 583 

Dislocation, of first cervical vertebra produced by manipu- 
lation, 48; Old, of clavicle, 147; Fracture of, astragalus, 
372; Posterior, of lower humeral epiphysis as birth 
injury, 604 

Displacement, Operation of retro-, of uterus, 71, 402; 
Operation for posterior, of uterus, 296; Treatment of 
backward, of uterus, 500 

Disturbances, Thymic, in adult, 135 

Diuretic, Hexamethylenamine as urate solvent and, and 
its effect on reaction of urine, 92 

Dorsalis pedis artery. Aneurism of, 280 

Double uterus in its relation to diagnosis and treatment, 71 

Drainage, Cure of suppurated chancrous bubo by filiform, 
275; Treatment of septic wounds with, 292; Vesical, 
historical review and presentation of new apparatus, 
420; Responsibility for loss of, tube in body of child, 
497; for pus conditions in pelvis during pregnancy, 601 

Dressings, Wound, 127; of wounds based on 943 observa- 
tions, 583 

Drop-wrist, Splint for, 475 

Drum membrane. New method of opening, in purulent 
otitis media by means of trephine, 613 

Ductless glands and their relation to treatment of func- 
tional gynecological diseases, 592 

Duodenum, Anatomical and physiological subdivisions of, 
with pathogenesis of iilcer, 142; Roentgenoscopic 
examination of stomach and, 167; Congenital atresia 
of, treated by operation, 365; Chronic ulcer of, and 
its gastric repercussion, 366; Congenital stenosis of 
the, in an adult, 456; Perforated ulcers of stomach 
and, 550 

Duodenal ulcers. Perforating pyloric and, 252; Chronic 
gastric and, 253; with special reference to its X-ray 
diagnosis, 254; Surgical treatment of gastric and, 
254; Roentgenologic diagnosis of, 366 

Duodenal, use of polygram in gastro-, diagnosis, 390; 
tube as factor in diagnosis and treatment of gall- 
bladder disease, 466 

Duodenopyloric, Ulcer of, fornix, 35 

Dura, Large endothelioma of, compressing both frontal 
lobes, 449 

Dysmenorrhcea, Results in X-ray treatment of monor- 
rhagia, and uterine myoma, 71; with anteflexion and 
retrocession, 590 

Dysthyroidism, Blood-pressure in, 134 

Dystocia, by fixation of shoulders after birth of head, 178; 
Foetal, and caesarean section, 410 

EARS, Infections of, nose, and throat as primary foci 
for secondary infections, 612 
Eberthian strumitis, 541 

Eclampsia, causes, nature, and treatment, 78; Treatment 
of, 407; Frequency of puerperal, 596; Treatment of, 
596 
Economics, Surgeon's responsibility to, of the hospital, 585 



INDEX TO SUBJECT MATTER 



zui 



Ectopia, Makka's operation for, of bladder, 89 

Ectopic, Recognition and treatment of, gestation, 303; 
Rare form of single, kidney, 606 

Elastometer, (Edema by means of, 60 

Elbow, Resections of, in war surgery; functional end- 
results, 374; Treatment of injuries in vicinity of, 
joint, 374 

Electrocautery, Epithelioma of posterior pharyngeal wall 
cured with, 618 

Electromagnet, Extraction of piece of grenade from pleural 
cavity by, 359 

Elevation, Congenital bilateral, of scapula, 46; Congenital, 
of scapula, 147 

Elongation, Unilateral polypiform cedematous, of uterine 
cervix, 499 

Embolism, Venous thrombosis and, cause, significance, 
and consequence, 54; in arteries, 575; Cerebral fat, 
with reference to delirium and coma, 576 

Empyema, Treatment of chronic non-tuberculous, 240; 
Recent progress in operative treatment of, of thorax, 
544; Bismuth paste in chronic suppurative sinuses 
and, incorrect technique as cause of failure in its 
application, 545 

End-to-end suture of bile-ducts, 371 

Endamcebiasis, Tonsillar, and thyroid disturbance, 26 

Endocrine glands, Pseudohe;rmaphrodism, with abnormal 
function of, 175; Alterations of the, especially the 
thymus and of blood following vagotomy, 490 

Endogastrectomy, Total, 142 

Endometrium, Relation of, and ovary to haemorrhage from 
myomatous uteri, 589 

Endoscopic surgery of oesophagus and respiratory tract, 
617 

Endothelioma, Large, of dura compressing both frontal 
lobes, 449; of right bronchus removed by peroral 
bronchoscopy, 547 

End-results, of entero-biliary anastomosis, 37; Fracture 
of neck of femur; treatment and, of 55 cases, 41; in 
lunbilical hernia operations, 249; of resection of ovaries 
for microcj^tic disease, 301; Resections of elbow in 
war surgery; functional, 374; in cases operated for 
salpingitis, 503; of pleuropulmonary wounds by war 
projectiles, 548; of nephrectomy, 607 

Enteric, intussusception, 256 

Entero-biliary, End-results of, anastomosis, 37 

Enucleation, Technique of, thyroidectomy, 238 

Epididymis, Tuberculosis of seminal vesical and, 91 

Epididymitis, Paratyphoidal orchi, 422 

Epidural injections. Obstetrical analgesia by, of novocaine, 
411 

Epiglottal, Infra, cj^ts, 195 

Epilepsy, Acute angulation and flexure of sigmoid; a 
causative factor, in 463; Etiology of pelvic disease in, 

Epinephrin, Pharmacology of ureter; action of, ergotoxin, 
and nicotine, 165; Liberation of, from adrenal glands 
by stimulation of splanchnic nerves and massage, 
284; Effect of, on medullary centers, 285 

Epiphysitis, Retarded ossification as etiologic factor in 
traimiatic arthritis and, 40 

Epiploon, Extraction from abdomen of bullet encysted in, 
362; Surgery of posterior wall of stomach; method of 
choice in approaching rear cavity of, 365; and peri- 
colitis, 388 

Epitheliimi, Effects of cancer tissue and normal, on 
vitality of protozoa, 273 

Epithelioma, Treatment of, of lower lip, 389 

Ergotoxin and nicotine. Pharmacology of ureter; action 
of epinephrin, 165 

Essential haemorrhage of uterus, 499 



Ether, Use of warmed, vapor for anaesthesia, 129; Anti- 
septic action of, in peritoneal infections, 248; Organic 
depression of nerve-cell produced by prolonged, 
anaesthesia, 578; Relation of, pneiunonia to pelvic 
and abdominal surgery, 593 

Ethmoidal region. Malignant hypernephroma of, 428 

Etiology, and prophylaxis of cancer, 50; of congenital 
absence of parts, 154; of pelvic disease in epilepsy, 
592 

Eusol, Application of, 18 

Eventration of diaphragm, with report of right-sided 
eventration, 32 

Excision, Partial, of thyroid cartilage as an alternative 
to thyrotomy in malignant disease of vocal cord, 315; 
versus gastro-enterostomy in treatment of gastric 
ulcer, 551 

Exophthalmos, Attempts to produce, experimentally, 
165; Pulsating, 425 

Exophthalmic goiter. Cerebral nerve disturbances in, 133; 
Metabolism in, 485 

Exostoses, Multiple cartilaginous, 39; Subungual, 40; 
Multiple cartilaginous, 472 

Experimental, surgery of mediastinimi, excluding the 
heart, 59; Pathological aspects of some problems of, 
cancer, research, 60; grounds for treatment of lung 
tuberculosis by X-rays, 61; Bacteriological and, 
research on gas gangrene, 64; Pyloric exclusion an, 
and clinical study, 142; alterations produced by 
micrococcus melitensis, 165; Attempts to produce, 
exophthalmos, 165; Serum changes and cause of 
death in, pancreatitis, 262; researches on regenera- 
tion and neoformation of lymph-glands, 284; Bac- 
teriology and, production of ovaritis, 300; researches 
on mechanism of menstruation, 302; cloudy swelling 
of kidney in rabbit, 308; Clinical and, study of 
postoperative ventral hernia, 347; study of use of 
sodiiun citrate in transfusion of blood by direct and 
indirect methods, 379; study of additive and antago- 
nistic actions of sodimn oxalate and salts of mag- 
nesium and calcium in the rabbit, 387; Tubercular 
bacillaemia, 388; colonic stasis, 462; h3q)ercholes- 
terolaemia, 485; Bacteriological and, studies on gastric 
ulcer, 486; renal sporotrichosis, 487 

Expert evidence as to treatment; patients' duty to 
minimize damage, 294 

Exploration, Tonsilloscope and, of interior of tonsils in 
situ, 617 

Extension, Treatment of fractiires by suspension and, 474; 
splint for fractures of humerus, 564 

Extraction, New method of bullet, 228; of bullets from 
bladder by natural route, 419 

Extra-uterine, Treatment of, pregnancy in advanced 
periods, 407 

Extremities, Conservative treatment of gangrene of, due 
to thrombo-angiitis obliterans, 53 

Eye, Injuries of deep membranes of, in war with integrity 
of ball, 193; Liberation of epinephrin from adrenal 
glands by stimulation of splanchnic nerves and by 
massage, studied by means of denervated reaction, 
284; X-ray localization of foreign bodies in, by Sweet 
method, 611 

FACE, War injuries of jaw and, 350; Very extensive 
shell wound of, reduction of ensuing deiformity by 
extirpation of the cicatrix, 350 
Faecal fistula. Prevention of, in suppurative appendicitis, 

368 
Faecal, Unusual, and genito-urinary cases treated by bis- 
muth paste, 514 
Faucial tonsil, Physicomechanical fimction of, 430 



XIV 



INTERNATIONAL ABSTRACT OF SURGERY 



Feet, Deformities of, 46; Subastragalar arthrodesis in 
lateral deformity of paralytic, 153; Paralytic, 268; 
Subastragalar arthrodesis in lateral deformities of 
paralytic, 478; and their care, 569 

Femur, Fracture of neck of; treatment and end-results of 
SS cases, 41; Treatment of oblique fracture of, 146; 
Fracture of, 564; Intracapsular fracture of, 565 

Femoral aneurism. Treatment of, 162 

Ferments, Blood, in pregnancy, 506 

Fibroid, Radium treatment of uterine, 70; Complicating 
pregnancy, 305; Degeneration of appendix, 256 

Fibroma, Technique of new procedure for subtotal abdom- 
inal hysterectomy in uterine, or inflammation of 
adnexae, 296; Symmetrical pressure, 472 

Fibrous tissue. Origin and structure of, formed in wound 
healing, 487 

Field hospitals, Secondary union of war wounds by first 
intention in the, 494 

Filter, for deep roentgen therapy, 61 

Fissure in ano, Observation on, 466 

Fistula, Vesical, due to permanent foreign body in bladder, 
189; Congenital cysts and, of the neck, 350; Anorec- 
tal, 259; Prevention of fascal, in suppurative appendi- 
citis, 368; Menstrual, of abdomen, 404; Operative 
treatment of partial staphyloma of cornea and, of 
cornea with conjunctival flap, 611; Orbital and peri- 
orbital, 425 

Fixation, Artificial periosteum for, of shaft fractures, 41; 
Dystocia by, of shoulders after birth of head, 178; 
New method of fracture, 264; Method of treating 
gunshot fractures by external, apparatus, 264 

Flail-foot, Stabilizing the, in infantile paralysis, 479 

Flapless amputation, 268 

Flat-foot, Superstition of, 46; Autogenous bone-graft pin 
in treatment of painful and paralytic valgus, 266; 
Methods used in, at Yale, 479 

Fluoroscope, Use of, to avoid leaving gauze pads and 
sponges in the abdomen, 127 

Focal infections; results of overcoming same, 517 

Foetus, Teratoid tumor of anterior region of neck in human, 
at term, 541 

Foetal, Appearance of pressor substance in, hypophysis, 
388; Dystocia and caesarean section, 410 

Foot, Superstition of flat-, 46; Methods used in flat-, at 
Yale, 479; Congenital club-, 269; Painful anterior 
arch of, operation for relief by raising the arch, 269; 
Partial amputations of, for gunshot wounds of war, 
375; Golfer's, 376; Stabilizing the flail-, in infan- 
tile paralysis, 479; Soldier's foot and treatment of 
common deformities of, 479 

Forceps, High, operation, 80 

Foreign bodies. Exact localization of, by means of roentgen 
rays, 61; Vesical fistula due to permanent, in blad- 
der, 189; Removal of intracranial, under X-rays, 232; 
Removal of, from oesophagus and bronchi; new instru- 
ments, 242; Accurate method of localization of, in 
chest and their removal, 288; Removal of bullets and 
metallic, 289; in respiratory tract, 360; Ablation of, 
from heart followed by recovery, 361 ; in bladder result- 
ing from gunshot wounds, 420; Movements of, in brain, 
448; Anatomical position of localized, 492; Bron- 
chiectasis and bronchiectatic symptoms due to, 547; 
X-ray localization of, in eye by Sweet method, 611 

Fractures, of neck of scapula, 41 ; Device for intramedul- 
lary, splinting, 43; splints, 232; War, 145; records; 
effort towards standardization, 146; Bony union in 
intracapsular, of hip-joint, 146; of lumbar vertebrae 
and transverse processes, 155; of odontoid process of 
axis, 156; Diagnosis of, by physical examination 
versus skiagraphy, 263; problem, 263; Causes of 



prolonged disability from, 264; Uses and limitations 
of stereoscopic radiograms in diagnosis of injury to 
bone after-treatment of, 287; Pneumococcic and 
meningococcic meningitis after, of base of skull, 353; 
Results of, of OS calcis, 372; dislocation of astragalus, 
372; of tuberosities of tibia, 372; of larynx, 431; 
Blue sclerotics; their relation to multiple, in childhood, 
472; in children, 564; Malunited and ununited, 473; 
Isolated, of head of radius, 473; CoUes', 473; 
Sprains and sprain-, of the wrist-joint, 564; Rupture 
of bladder associated with, of pelvis, 512; Pathologic 
anatomy of the immediate lesions in penetrating cra- 
nial, due to projectiles, 538; of arteries, 575 

Fractures of femur, 564; Treatment and end-results in, 41; 
Treatment of oblique, 146; Intracapsular, 565 

Fractures, Treatment of, 474; Maxillary, 21; Artificial 
periosteum for fixation of shaft, 41; Plea for con- 
servative, 147; Operative, in war, 147; Transplanta- 
tion of bone in ununited, of shaft of humerus, 264; 
Extension splint for, of humerus, 564; Transplanta- 
tion of bone in ununited, of shaft of humerus, 568; 
New method of, fixation, 264; Gunshot, by external 
fixation apparatus, 264; Surgical procedures in gun- 
shot, of mandible, 350; Gunshot, 565; Primary resec- 
tion in treatment of articular gunshot wounds with, 
566; Gunshot, 373; of thigh in war surgery, 371; 
Immediate reduction of, 373; Open operation for, 373; 
by suspension and extension, 474; Choice of method 
in treatment of, 474; Operative treatment of simple, 
565; Autogenous bone-splints in, and tuberculous 
spines, 568 

Frontal lobes. Large endothelioma of dura compressing 
both, 449 

Frozen limbs and their treatment in present war, 561 

Fulguration, Cauterization and, of bladder tumors, 89 

Function, of thyroid parathyroid apparatus, 134; of kidney 
when deprived of its nerves, 188; Histochemical re- 
search regarding the, of the decidua, 306 

Functional, status of amputation stumps in war, 148; 
Complete nerve sections treated by suture with, 
restoration in injured nerves, 273; Ductless glands 
and their relation to treatment of, gynecological dis- 
eases, 592 

Furunculosis, Vaccine therapy and other treatment in acne 
vulgaris and, 481 

GALL-BLADDER, Time for operating in acute appen- 
dicitis and, disease, 258; Operation for removing the, 
261; Infolding and peritonealizing stitch with appli- 
cation of the same to broad ligament and, 346; 
Duodenal tube as factor in diagnosis and treatment 
of, disease, 466; Cholecystitis; changes produced by 
removal of gall-bladder, 468; Surgery of, and biliary 
passages, 556 

Gall-stone, diagnosis by roentgen ray, 262; Negative and 
positive roentgen diagnosis of, 370; Recurrence, of 
symptoms after operation for, disease, 467 

Galvanocautery operation for lower turbinate, 97 

Gangrene, Conservative treatment of, of extremities due 
to thrombo-angiitis obliterans, 53; Bacteriological and 
experimental research on gas, 64; Pulmonary, of 
otitic origin, 135; Pathology of gas, 383; Presenile,- 
thrombo-angiitis obUterans, 483; Gaseous, in war 
surgery, 493 

Gangrenous, Bacteria of, wounds, 283 

Gas burns, 384 

Gas gangrene. Bacteriological and experimental research 
on, 64; in present war, 289; Pathology of, 383; in 
war surgery, 493 

Gas-oxygen, Apparatus for administration of, 18 



INDEX TO SUBJECT MATTER 



XV 



Gastrectomy, Total endo, 142 

Gastric, Roentgen-ray diagnosis of, lesions, S3', Roentgen 
studies after, and intestinal operations, 34; Ionic con- 
centration of, contents in some stomach diseases, 249; 
Time relations of, pains with reference to gastric ad- 
hesions, 249; volvulus in hour-glass stomach of con- 
genital malformation, 249; Chronic ulcer of duodenimi 
and its, repercussion, 366; Fractional methods of 
examination of, contents, 549; Advantages of sep- 
arate suture of mucous membrane in, surgery, 551 

Gastric ulcer, following removal of adrenals, 33; Etiologic 
relationship existing between, and gastric cancer, 140; 
Trophic element in origin of, 140; Treatment of, 141; 
Cause of, 250; Traiunatic, 251; and duodenal ulcer, 
chronic, 253 ; Multiple acute, after using Percy's cold 
iron for inoperable carcinoma, 365; Bacteriological 
and exi)erimental studies on, 486; Surgical treatment 
of, 254 

Gastroduodenal, Use of polygram in, diagnosis, 390 

Gastro-enterostomy, Prevention and treatment of some 
obscure conditions complicating convalescence after, 
229; Excision versus, in treatment of gastric ulcer, 551 

Gastro-intestinal, Roeptgenographic findings in, tract, 33 ; 
Infections of mouth, nose, and throat, as primary foci 
for infections in, 139; examinations by roentgen ray, 
288; Roentgen diagnosis of obscure lesions of the 
tract, 391 

Gaucher's, Lipin content of, disease in infant, 39 

Gauze, Non-adhering surgical, 17; Use of fluoroscope to 
avoid leaving, pads and sponges in the abdomen, 127; 
Sheet rubber suf)erior to, sponges in abdominal oper- 
ations, 535 

Genital, Syphilis of internal, organs in female, 74; Diagno- 
sis and prognosis of uro, tuberculosis, 92; External, 
deformity due to retardation in morphologic evolution 
301; Treatment of, prolapse, 405 

Genito-urinary, Caudal anaesthesia in, surgery, 19; s)Tnp- 
toms arising from anal, rectal, and colonic diseases, 93; 
Diagnosis of, tuberculosis, 192; Unusual faecal and, 
cases treated by bismuth paste, 514 

Gestation, Recognition and treatment of ectopic, 303; 
complicated by appendicitis, 597 

Glands, Physiology of parath3rroid, 26; Non-surgical treat- 
ment of tuberculous, 133; Pineal, 284; Anatomy and 
surgery of thyroid, 449 

Glaucoma, Sclerocorneal trephining in, 515 

Glioma of cerebellum with metastases, 24 

Goiter, Cerebral nerve disturbances in exophthalmic, 133; 
^letabolism in exophthalmic, 485 

Golfer's foot, 376 

Gonococcic, Treatment of, conjunctivitis by autogonococ- 
cic serum, 94 

Gonorrhceal, Surgical treatment of, tube infection with a 
quarantine pack, 77; Treatment of, ophthalmia, 81; 
Complications of acute, in the male, 192; Infection 
of urethral glands, 190 

Graft, Pott's disease treated by bone-, 44; Treatment of 
large crural hemiae by pediculated adipose, 364; 
Osteoperiostic, taken from tibia to serve in recon- 
struction of bone or in repair of loss of osseous sub- 
stance, 476; Transplantation of bone and some uses 
of bone-, 568; Bone-, for spinal conditions, 47 

Graves' disease, Sclerodermia associated with, and later 
myxoedema, conspicuously benefited by implantation 
of himian thyroid into bone-marrow, 238 

Growths, Pituitary feeding upon, and sexual development, 
131; Malignant transformation of benign, 465 

Gunshot fractures, Method of treating, by external fixation 
apparatus, 264; Surgical procedures in, of mandible, 
350; Treatment of, 373, 565 



Gunshot injuries, of peripheral nerves; syndrome of com- 
pression, 156; Plastics of penetrating cheek defects 
due to, 232; Ankylosis following, of joints, 270; In- 
juries of spinal cord with, of cord at fourth cervical 
vertebra and successful removal of projectile, 377; 
Treatment of diaphysary, in ambulance at the front, 
561 

Gunshot wounds, of head, 20; of thorax, 28; Abdominal, 
30; of soft parts, 63; Treatment of, 65; in upper 
limbs, 167; retention, 167; of cranium, 232; Radiog- 
raphy in, of skull, 232; of chest, 239; Symptoms and 
complications of, of solid abdominal viscera, 246; of 
spine, 270; and injuries of spinal cord, 271; Treat- 
ment of, of spine, 271; arteriovenous aneurism in 
which the sac was situated on side opposite the vein, 
280; Auscultation in diagnosis of vascular injuries 
accompan)ang, 281; Partial amputations of foot for, 
of war, 375; Foreign bodies in bladder resulting from, 
420; Treatment of, in bladder, 420; Treatment of, of 
testicle, 422; of abdomen in pregnant women, 507; 
Articular, 563; Primary resection in treatment of 
articular, with fracture, 566 

GjTiecology, Psychiatry and, 302; Diagnosis in, 404 

Gynecological, Ductless glands and their relation to treat- 
ment of functional, diseases, 592 

O^MATOLOGY in obstetrics, 603 

A A Haematoma, Suppurative, of iliac fossa, 277 

Haematuria, Unilateral, 86; Unilateral, associated with 
fibrosis and multiple microscopic calculi of renal 
papillae, 510 

Haemolysis, Relation of, in transfusion of babies with 
mothers as donors, 56 

Haemophilia, Blood and blood-vessels in, and other haemor- 
rhagic diseases, 53 

Haemorrhage, Pillar-compression forceps for controlling, 
following tonsillectomy, 20; Intracranial, due to 
traumatic rupture of arteria meningea media, 22; 
Secondary, in military surgery, 52; Lacing the lingual 
artery for secondary, of the tongue, 162; Associated 
with partial and complete detachment of normally 
implanted placenta, 304; Significance of, in operations 
on nose and throat, 314; Control of, in extensive 
operations on nose and jaws, 427; Essential, of uterus, 
499; Secondary tonsillar haemorrhage, 516; Present 
conditions in treatment of, due to low insertion of the 
placenta, 599; Blood- transfusion in, of newborn, 604 

Haemorrhagic, Blood and blood-vessels in haemophilia and 
other, diseases, 53; New, operation; snare and bullet, 
261; Blood-transfusion in treatment of severe post- 
haemorrhagic anaemia and, diseases, 279; Acute, pan- 
creatitis, 557 

Haemorrhoids, Treatment of, by injection, 260; Bloodless 
operation for, and prolapsus ani, 261; Treatment of, 
by new method, 466 

Hallux, rigidus, 269; valgus, 376 

Head, Gunshot wounds of, 20; Immediate treatment of, 
injuries from projectiles, 129; Treatment of, injuries 
in casualty clearing station, 477 

Healing, Origin and structure of fibrous tissue formed in 
wound, 487 

Heart, Ablation of foreign body from, followed by recov- 
ery, 361; Projectile penetrating and lodging in, 361; 
Projectile in right lobe of, after traversing cava in- 
feriore, 453; Management of pregnancy and labor 
complicated by, -disease, 598 

Heat, as method of treatment in inoperable uterine carci- 
noma, 69; Use of, in control of inoperable cancer, 498 

Heliotherapy, General, in treatment of bone and joint 
afifections, 263 



XVI 



INTERNATIONAL ABSTRACT OF SURGERY 



Hemiplegics, Orthopedic treatment in, 569 

Hepatoptosis, Partial, due to interposition, 370 

Hermaphrodism, Pseudo, with abnormal function of 
endocrine glands, 175 

Hernia, Retro-inguinal, 248; End-results in umbilical, 
operations, 249; Clinical and experimental study of 
postoperative ventral, 347; Treatment of large crural, 
by pediculated adipose graft, 364; in relation to in- 
testinal stasis, 455; of urinary bladder, 512; Patho- 
genesis and treatment of precocious, persistent, cere- 
bral, 540 

Heterogenous bone-peg, 266 

Hexamethylenamine as urate solvent and diuretic; effect 
on reaction of urine, 92 

Hexamine as urinary antiseptic, 189 

High explosives. Effects of, upon central nervous system, 63 

High forceps, operation, 80; Caesarean section, pituitary 
extract, 303 

Hip-joint, Bony union in intracapsular fractures of, 166; 
Osteomyelitis involving the, 473 

Hirtz compass, Operative technique of extraction of pro- 
jectiles under guidance of, 170 

Hospital, Post-, care of surgical patient, 59; Proposed 
equipment for, corps, 293; Organization and prob- 
lems of war, 293; Surgeon's responsibility to economics 
of, 585 , 

Himierus, Resection of, for fistulous osteomyelitis, 44; 
Transplantation of bone in ununited fractures of shaft 
of, 264; Extension splint for fractures of, 564; Trans- 
plantatioh of bone in ununited fractures of shaft of, 568 

Hiuneral epiphysis. Posterior dislocation of lower, as birth 
injury, 604 

Hydatidiform mole, 302 

Hydrocele, Vaginal, operated upon by inguinal route, 191 

Hydrocephalus, Pathological bases of, to its surgical alle- 
viation, 23; Dififerentiation and treatment of, 23; 
Anatomical cause of frequency of, in childhood, 448 

Hydronephrosis, Large congenital, in an infant, 85; Mul- 
tiple ureters with, 189 

Hydrops tubae profluens, 301 

Hygroma, Cystic, in infant, 185 

Hypercholesterolaemia, Experimental, 485 

Hypernephroma, Origin of, of kidney, 416; Malignant, of 
ethmoidal region, 428 

Hyperthyroidism, Quinine and urea injections in, 236 

Hypochlorous acid. Surgical and antiseptic values of, 1 7 

Hypodermatic treatment of joint injuries, 374 

Hypophysary, Cachexia of, origin, 378 

Hypophysis, Appearance of pressor substance in foetal, 388 ; 
Clinical considerations of lesions of, 449 

Hypophyseal disorder in mammary cancer, relation to 
diabetes insipidus, 135 

Hypothalamic, Tumors of, region of middle brain, 355 

Hysterectomy, Technique of new procedure for subtotal 
abdominal, in uterine fibroma or inflammation of 
adnexae, 296; Vaginal, 501; Vaginal, for procidentia, 501 

ILEUM, Complete congenital atresia of, 458 
Heus, Post-operative, 367; Absence of muscular tone 
an etiological factor in postoperative, 459 

Iliac fossa. Suppurative haematoma of, 277 

Immune-reactions against tmnor-growth in animals with 
spontaneous tumors, 158 

Immunity, Continuous transfusion in production of, 161; 
Timior, 274; conferred by transfer of immune and 
mixed immune and sensitized serums, 574 

Implantation, Sclerodermia associated with Graves' dis- 
ease, and later myxoedema, conspicuously benefited 
by, of human thyroid into bone-marrow, 238; Sex- 
gland, 424 



Inanition, Effects of tethelin; recovery of weight lost dur- 
ing, and in healing of wounds, 286 

Industrial accident. Ocular tuberciilosis secondary to, 312 

Infant, Operative treatment of pyloric obstruction in, 34; 
Injuries to, produced at birth, 82; Cystic hygroma 
in, 185 _ 

Infantile paralysis. Deformities due to, operative treat- 
ment, 45; Tendon- transplantation in, 45; Non- 
operative treatment of, 46; Result of astragalectomy 
in, 153; Treatment of, 478; Stabilizing the flail-foot 
in, 479 _ 

Infection, Chronic general, with baciUus pyocyaneus, 58; 
Non-surgical, of kidneys and ureters, 84; of mouth, 
nose, and throat as primary foci for infections in 
gastro-intestinal tract, 139; of mouth, ear, nose, and 
throat as primary foci for secondary infections, 196; 
Roentgenologic examination in elimination of mouth 
as source of, in systemic disease, 315; Oral sepsis as 
focus of, 315; Torula, in man, 400; Puerperal, 413; 
Regeneration of long bones following, 472; Focal 
results of overcoming same, 517 

Infected, Treatment of, wounds by physiological methods, 
584; Treatment of, suppurating war wounds, 584 

Infiltration, Method of faqijitating, anaesthesia, 349 

Inflammations, Treatment of non-tuberculous, of seminal 
duct, 91 

Inflammatory, Diagnosis and treatment of, affections of 
the nasal accessory sinuses, 96 

Influenza, Aural complications of, 94 

Influenzal, Acute mastoiditis with, meningitis; treatment 
by operation on mastoid and anti-influenzal serum, 94 

Infra-epiglottal cysts, 195 

Infusion, Intravenous continuous, at front, 379 

Inguinal, hernia from medicolegal aspect, 171; Incision for 
intrascrotal affections, 191; Vaginal hydrocele oper- 
ated upon by, route, 191; Retro-, hernias, 248 

Injections, Collargol, in small doses, 52; Quinine and urea, 
in hyperthyroidism, 236; Treatment of haemorrhoids 
by, 260 

Injuries, Deformities of jaws resulting from operation or, 
21; War, of jaw and face, 130, 350; Immediate treat- 
ment of head, from projectiles, 129; Treatment of 
head, in casualty clearing station, 447; of the large 
blood-vessels in war, 57; to infant produced at birth, 
82; War, of urogenital system, 85; of lower spine, 155; 
of deep membranes of eye in war with integrity of ball, 
193; Immediate and after-treatment of railway, 238; 
Diagnosis and treatment of brain, in adults, 355; 
Hypodermatic treatment of joint, 374; Treatment of, 
in vicinity of elbow-joint, 374; Experience with vas- 
cular, 381; Manual expression of bladder in spinal, 
421; Technical features of laminectomy for spinal dis- 
ease and, based on 150 spinal operations, 569; Ano- 
rectal, 465 ; War, 493 ; of lower back, 569 ; of bladder 
and urethra in war, 609; to undiseased parts in per- 
formance of operations, 496 

Inoculation, Intraperitoneal, of animals, its diagnostic 
value in orthopedic surgery, 154 

Internal secretions. Histologic physiopathologic research 
on, of pancreas in pregnancy, 184; Myopathy related 
to disorders of, 481 

Interposition, Partial hepatoptosis due to, 370 

Intestine, Strangulated fallopian tube, ovary and, in an 
infant, 74; Treatment of devascularized, 367; Paral- 
ysis of, after resection for gunshot injuries, 551; Pro- 
cess of repair in wounds of small, 552; Anatomy, 
physiology, and pathology of large, 553 

Intestinal, Roentgenographic findings in gastro-, tract, 33; 
Roentgen studies after gastric and, operations, 34; 
adhesions, 255; stasis, 256; function in pancreopathic 



INDEX TO SUBJECT MATTER 



xvu 



conditions, 386; Roentgen diagnosis of obscure lesions 
of the gastro-, tract, 391; Hernia in relation to, stasis, 
455; obstructions; non-coagulable nitrogen of blood, 
456; High, stasis, 458; Carcinoma of colon causing, 
obstruction, 554 

Intracranial, aerocele, 130; Semicircular apparatus of ear 
and cerebellar localization as diagnostic key to, con- 
ditions, 194; Removal of, foreign body under X-rays, 
232 

Intraperitoneal inoculation of animals, its diagnostic value 
in orthopedic surgery, 154, 477 

Intratracheal injection, Absorption of adrenalin after, 489 

Intra-uterine, Adjustment of, stem versus dilatation to 
overcome stenosis of cervical canal, 1 73 ; crying, 508 

Intravenous, Injections of lactose without reaction, 87; 
Disappearance of dextrose from blood after, injection, 
277; continuous infusion at front, 379; injection of 
magnesium sulphate for anaesthesia in animals, 386 

Intussusception, Enteric, 256; Early diagnosis of, in chil- 
dren under three years of age, 457 

Iodine in tetanus, 282 

Ionization, Cancer subjected to surgical, 158 

Ionic concentration of gastric contents in some stomach 
diseases, 249 

Irrigation, Continuous, of wounds in field, 347 

Ischiorectal abscess from fish-bone, 259 

Ischiopubic disconnection. Total, of deep perineal fascia, 
421 

JAWS, Deformities of, resulting from operation or injury, 
21; War injuries of, and face, 130; War injuries of, 
and face, 350; Control of haemorrhage in extensive 
operations on nose and, 427 

Jejuniun, Ulcer of, 35 

Joints, Tuberculosis of, Changed character of later lesions 
occurring in healed, 145; Necessity of operation in, 
475; Treatment of abscesses in, and bones, 475; 
Value of roentgenology in treatment of bone and, 581 

Joints, Treatment of infected, in war, 42; Overlapping, as 
substitute for cuneiform osteotomy, 43 ; Loose bodies 
in knee-, 263; Treatment of unstable cartilages of 
knee-, 567; Heliotherapy in treatment of bone and, 
affections, 265; Arthroplasty of interphalangeal, 265; 
Ankylosis following gunshot injuries of, 270; Hypo- 
dermatic treatment of, injuries, 374; Treatment of 
injuries in vicinity of elbow-, 374; Osteomyelitis in- 
volving the hip-, 473 

KERATITIS, Rosacea, and other forms of marginal 
keratitis, 94 

Kidney, Non-surgical infection of, and ureters, 84; Urine 
stasis in etiology of pyogenic, infections, 84; tipping 
by grenade splinter, 85; Intravenous injections of 
lactose without reactions; Sclayer's, test, 87; Inhi- 
bition of toxicity of anaesthetics for nephropathic, 128; 
Congenital cystic, 186; Function of, when deprived 
of its nerves, 188; Surgery in, conditions, 188; Experi- 
mental cloudy swelling of, in rabbit, 308; Malignant 
txunor of right, in chUd, 416; Origin of hypernephroma 
of, 416; Abscess of, cortex and its relation to parane- 
phritic suppuration, 416; Surgical replacement of 
prolapsed, 510; Rare form of single ectopic, 606; 
Diagnosis of certain surgical lesions of, 606; Sarcoma 
of, treated by roentgen ray, 607; Pyelo-ureterography 
as aid in diagnosis of obscure surgical conditions of, 
and ureter, 608 

Killian operations. Extensive cholesteatoma following Luc- 
Caldwell and, 616 

Ximpton-Brown, Direct blood-transfusion with, tubes, 280 



Knee, Treatment of purulent arthritis of, by arthrostomy 
or marsupialization of synovial sac, 40; Loose bodies 
in, -joint, 263; Treatment of traumatic arthritis of, 
567; Treatment of unstable cartilages of, -joint, 
567 

Kyphosis, Dermatolysis and molluscum fibrosum with 
congenital morbus cordis and, 275 

1 ABOR, Pituitrin in, 81; Uses of pituitary extract in, 

•L' 183; obstructed by ovarian cyst, 305; Management of 
ovarian ttunors complicating pregnancy, and puer- 
perium, 409; Anaesthesia in, 411; Rupture of uterus 
during, 411; Scopolamine-morphine anaesthesia in, 
507; Pituitrin in, 508; obstructed by ovarian cyst, 
599; Use of chloroform in first stages of, 600; Effects 
of nutrition of mother during pregnancy and, on con- 
dition of child, 602 

Laboratory, Study plan for diagnostic team action as, for 
profession, 399; Free tumor diagnosis as function of 
state public health, 399 

Labyrinth, New method of examining the vestibular, 515 

Lacerations, Operating dm-ing puerperiimi for cure of old, 
of cervix and perineum, 406; of cervix, 69 

Lachrymal, Digital compression of, sac in sacryocystitis of 
newborn, 312 

Lactation, Uncontrollable vomiting of, 602 

Lactose, Intravenous injections of, without reaction, 87 

Laminectomy, Technical features of, for spinal disease and 
injury, 569 _ 

Larynx, War injiuries of, and trachea, 360; Fractures of, 
431; Agioma of, 517 

Laryngology, Use of radiima in field of, 581 

Lavage, Treatment of chronic colon bacUlus pyelitis by 
pelvic, 417 

Leptomeningitis, Circumscribed purulent, due to frontal 
sinusitis, 354 

Lesions, Changed character of later, in healed tuberculous 
joints, 145; Clinical considerations of, of hypophysis, 
449; Diagnosis of certain surgical, of kidneys, 606 

Leucocyte count of appendicitis, 461 

Liability contract, Interpretation of physicians', 171 

Ligaments, Shirring round, 403 

Ligature, Combination needle-holder and, scissors, 129; 
Behavior of pancreatic ferments in blood after, of 
pancreatic ducts, 286 

Lingual artery. Lacing the, for secondary haemorrhage of 
the tongue, 162; Ligature of, in triangles of Beclard 
and Pirogoff, 197 

Lip, Treatment of epithelioma of lower, 389 

Lipin content of Gaucher's disease in infant, 39 

Lipoid content of maternal and foetal blood, 508 

Lithium carbonate. Uric acid solvent power of urine after 
administration of piperazine, lysidin, and other alka- 
lies, 60 

Liver, The spleen its association with, and relation to cer- 
tain conditions of blood, 38; Extirpation of spleen in 
pathology of, and blood, 144 

Local and general anaesthesia, 19; Tonsil operation under, 
98; Appendectomy under, 258; Transvesical pros- 
tatectomy under, 424 

Localization, of cerebellar tumors, 24; Exact, of foreign 
bodies by means of roentgen rays, 61; Cerebellar, in 
light of recent research, 234; Accurate method of, of 
foreign bodies in chest and their removal, 288; of 
cerebellar tumors; the pointing reaction and caloric 
test, 355 

Localized foreign bodies. Anatomical position of, 492 

Lower uterine segment; its origin and boundaries, 79 

Lumbar vertebra, Extraction of shrapnel bullet from 
third, 570 



XVlll 



INTERNATIONAL ABSTRACT OF SURGERY 



Lung, surgery, 136; Abscess of, after tonsillectomy, 196; 
Phrenicotomy in treatment of some chronic diseases 
of, 360; Indirect traumatisms of, due to nearby explo- 
sion of large war projectiles, 361; abscess following 
tonsillectomy, 516; Late extraction of intrapulmonary 
projectiles; operative technique of, surgery, 548; 
Removal of fragment of tracheotomy tube from, six 
years after inspiration, 548 
Lupus vulgaris. Use of artificial chemical light in, 572 
Lymph-glands, Bacteria associated with certain types, of 
abnormal, 162; Experimental researches on regenera- 
tion and non-formation of, 284 
Lymphatics, Anatomic study of, of breast from viewpoint 

of lymphatic extension of cancer, 542 
Lymphocytosis, Importance of, of blood, 378 
Lymphosarcoma, Chylothorax, chylous ascites, and, 454 
Lysidin, Uric acid solvent power of urine after administra- 
tion of piperazine, lithiimi carbonate, and other alka- 
lies, 60 

MAGNESIUM, Present status of, sulphate in treatment 
of tetanus, 383; Intravenous injection of , sulphate for 
anaesthesia in animals, 386; Experimental study of 
additive and antagonistic actions of sodium oxalate, 
and salts of, and calciimi in the rabbit, 387 

Makka's operation for ectopia of bladder, 89 

Malignant, pustule treated by Baccelli's method, 378; 
Roentgen deep therapy in, timiors, 391; tumor of 
right kidney in child, 416; disease of nose or accessory 
sinuses; advantages of operating through face, 427; 
hypernephroma of ethmoidal region, 428; transforma- 
tion of benign growths, 465; Deep roentgen therapy of 
benign and inoperable, conditions by improved tech- 
nique, 491 

Malignancy, Faulty treatment of superficial, 481 

Malunited and ununited fractures, 473 

Mammary, Relation of, glands to nervousness and men- 
struation, 176; Tuberculosis of, 240; Acute, carci- 
noma, 451; Rare, timior, 452 

Mammary: See also Breast 

Management, of compUcations in pregnancy, 598; of preg- 
nancy and labor complicated by heart-disease, 598 

Mandible, Surgical procedures in gunshot fractures of, 350 

Marsupialization, Treatment of purulent arthritis of knee 
by arthrostomy or, of synovial sac, 40 

Mastitis, Relation between chronic, and carcinoma of 
breast, 451 

Mastoid, Obscure cases of, involvements, 95; Streptococ- 
cus mucosus capsulatus infection of, bone, 612 

Mastoiditis, Acute, with unusual symptoms indicative of 
intracranial involvement; operation; recovery, 94; 
Acute, with influenzal meningitis treatment by opera- 
tion on mastoid and anti-influenzal serum, 94; Cor- 
roborative diagnosis of, by means of X-ray, 515; 
Chronic suppurative, accompanied by intracranial 
pressure, 515 

Maternal, Lipoid content of, and foetal blood, 508 

Maternity Hospital, Technique at Jewish, and its results, 

307 

Maxillary, Treatment of, fractures, 21 

Mechanism of meristruation. Experimental researches on, 
302 

Mediastinum, Experimental surgery of, excluding the 
heart, 59; Surgical treatment of suppurations in pos- 
terior, 545 

Mediastinal tumor treated by radiotherapy, 453 

Medicolegal, Inguinal hernia from present-day, aspect, 171 

Medullary, Effect of epinephrin on, centers, 285 

Melanosarcoma of buccal mucosa, 517 

Menmies devii. Compensatory menstruation, xenomenia, 70 



Meningitis, Acute mastoiditis, with influenzal, treatment 
by operation on mastoid and anti-influenzal serum, 94; 
Pnemnococcic and meningococcic, after fracture of 
base of skull, 353; Circimiscribed purulent lepto, due 
to frontal sinusitis, 354 

Menopause, Precocious, in virgins, 176 

Menorrhagia, Results in X-ray treatment of, dysmenor- 
rhoea, and uterine myoma, 71 

Menstruation, Compensatory; xenomenia, memmes devii, 
70; Relation of mammary glands to nervousness and, 
176; Experimental researches on mechanism of, 302 

Menstrual fistula of abdomen, 404 

Mental symptoms complicating acute tetanus during 
treatment by carbolic injections, 282 

Mercury-lamp, Results of combined, and deep X-ray treat- 
ment of human lung tuberculosis, 61 

Metabolism, Nitrogen, during pregnancy, 304; in exoph- 
thalmic goiter, 485; studies before and after splenec- 
torny in pernicious anaemia, 580; Basal, in disease and 
their importance in clinical medicine, 573 

Metastases, Glioma of cerebellmn with, 24; Cancer of 
mouth and tongue with reference to, in neck, 517 

Methods, Practical, in diagnosis, 169; Choice of, in treat- 
ment of fractures, 474; X-ray localization of foreign 
bodies in eye by Sweet, 611 

Metropathies, Indications for surgery or deep roentgen- 
therapy for myomata and, 174 

Micrococcus melitensis. Experimental alterations produced 
by, 165 

Micro-organisms, Protection of pathogenic, by living tissue- 
cells, 384 

Midwife, Supervision of, 184 

Migraine, 96 

Military surgery, 52 

Military: See also War, Foreign Bodies, Projectiles, Bul- 
lets, Wounds 

Mitochondria, Functional significance of, in toxic thyroid 
adenomata, 450 

MoUuscum fibrosum, Dermatolysis and, with congenital 
morbus cordis and kyphosis, 275 

Morbus cordis, Dermatolysis and molluscum fibrosum with 
congenital, and kyphosis, 275 

Morphine as an early diagnostic element in certain forms 
of acute appendicitis, 461 

Morphologic evolution. External genital deformity due to 
retardation in, 301 

Mortahty, Operative, 67; Neglected appendicitis; high 
diagnostic and therapeutic responsibility, 257; Fac- 
tors influencing, of peritonitis, 363 

Motion study in surgery, 586 

Motor nerves, Partial resection of, in spastic paralysis, 272 

Mouth, Infections of, ear, nose and throat as primary 
foci for secondary infections, 196; Roentgenologic 
examination in elimination of, as source of infection 
in systemic disease, 315; Cancer of, and tongue with 
reference to metastases in neck, 517 

Mucous membrane. Advantages of separate suture of, in 
gastric surgery, 551 

Muscle, Deposit in supraspinatus, simulating subacromial 
bursitis, 41; Tenotomy of inferior oblique, 313 

Muscular tone. Absence of, an important etiological factor 
in post-operative ileus, 459 

Myoma, Results in X-ray treatment of menorrhagia, 
dysmenorrhoea, and uterine, 71; Red, of uterus, 499 

Myomata, Indications for surgery or deep roentgen therapy 
for, and metropathies, 174; X-ray treatment of 
uterine, 402 

Myomatous uteri. Relation of endometriiun and ovary to 
haemorrhage from, 589 

Myopathy related to disorders of internal secretions, 481 



INDEX TO SUBJECT MATTER 



XIX 



Myositis, Talipes equinus through, of the triceps, 154 
Myxcedema, Solerodermia associated with Graves' disease 

and later, conspicuously benefited by implantation of 

human thyroid into bone-marrow, 238 

N^EVUS flammeus, Treatment of, and allied conditions 
by filtered ultraviolet rays, employing the'compression 
method of application, 491 

Narcosis, Sudden death in chloroform, 349; Dangers of 
chloroform, 446 

Nasal, Deaths attributable to intra, operations and other 
instrumentation, 97; Bacteriology of, sinus disease, 
516; Diagnosis and treatment of inflammatory affec- 
tions of the, accessory sinuses, 96; Diagnosis and 
treatment of inflammatory affections of, accessory 
sinuses, 427; Deviations of, septimi and submucous 
operation, 613 

Nasi, Pons, 232 

Nasopharynx, Carcinomata of, 96 

Neck, Resection in projectile woimds of, 26; Congenital 
cysts and fistulae of the, 350; resection in secondary 
period of traimiatic arthritis, 357; Teratoid timior of 
anterior region of, in human foetus at term, 541 

Needle-holder, Combination, and ligature scissors, 129 

Negligence, Burden of proof in actions for, 495 

Neonatorum, Treatment of ophthalmia, 81 

Nephrectomy, End-results of, 607 

Nephritis, Syphilitic, from standpoint of diagnosis and sal- 
varsan treatment, 186; Surgical treatment of, 417 

Nephritic, Abscess of kidney cortex and its relation to para, 
suppuration, 416; toxaemia of pregnancy, 596 

Nephropexy, 417 

Nephrosis, Large congenital hydro, in an infant, 85 

Nerve, Complete section of left radial, nerve-sutiire, 49; 
Inclusion of radial, in cicatrix; total radial paral5^is; 
liberation of the nerve, 49; Uniting of divided nerves, 
49; supply of lower abdominal wall as related to 
Pfannenstiel incision, 228; Complete, sections treated 
by suture, 273; Sutiure of, and alternative methods of 
treatment by transplantation of tendon, 375; -sutures, 
377; -blocking as practical method of anaesthesia for 
abdominal operations, 536; Isolation and protection 
of, -trunks in operations for restoration of nerves, 570; 
Intradural, anastomosis in selected cases of poliomye- 
litic paralysis, 571; Organic depression of, -cell pro- 
duced by prolonged ether anaesthesia, 578 

Nervous system. Effects of high explosives upon central, 63 

Neuralgia, Diagnosis and treatment of trifacial, 537 

Neurotomy, Rosacea keratitis and other forms of marginal 
keratitis, neuropathic in origin, treatment by peri- 
corneal, 94 

Newborn, Digital compression of lachrymal sac in dacryo- 
cystitis of, 312 

Nitrogen, metabolism during pregnancy, 304; Intestinal 
obstructions; non-coagulable, of blood, 456 

Nitrogenous constituents. Non-protein, of blood and 
phenolsulphonephthalein test in children, 483 

Nitrous-oxide, adnainistration, 128; -oxygen, the most 
dangerous anaesthetic, 536 

Non-surgical, treatment of tuberculous glands, 133; Can- 
cer as, disease, 571 

Nose, Bone- transplantation in, deformities, 21; Papilloma 
of, 96; Infections of mouth, and throat, as primary 
foci for infections in gastro-intestinal tract, 139; 
Wounds of, nasal fossas, and accessory cavities in time 
of war, 195; Infections of mouth, ear, and throat as 
primary foci for secondary infections, 196; Treatment 
of diseases of accessory sinuses of, 314; Significance of 
haemorrhage in operations on, and throat, 314; Ma- 
lignant disease of, or accessory sinuses; advantages of 



operating through face, 427; Control of haemorrhage 
in extensive operations on, and jaws, 427; Infection of 
ears, and throat as primary foci for secondary infec- 
tions, 611; Sarcoma of, with metastases in cervical 
glands and in brain, 613 
Novocaine, Obstetrical analgesia by epidural injections 

of, 411; Pharmacology of, 578 
NuUiparous, Prolapse of uterus in, women, 589 
Nursing period. Duration of the, in women, 306 
Nutrition, Effects of, of mother during pregnancy and labor 
on condition of child, 602 

OBSTETRICS, Analgesia and anaesthesia in, 81 ; Syphilis 
in its relation to, 82; Ideal, 185; Choice of anaes&etic 
and general analgesic in surgery and in, 307; Routine 
Wassermann reaction in hospital, 415; Results from 
pituitary extract in, 600; Significance of syphilis in, 
603 ; Haematology in, 603 

Obstetrical, Operation for correction of deformity due to, 
paralysis, 49; paralysis, 509; or brachial birth palsy, 
509; paralysis, 603 

Obstruction, Operative treatment of pyloric, in infants, 34; 
Pressure of bile secretion during chronic, of common 
bile-duct, 144; Treatment of general peritonitis with, 
248; Intestinal, non-coagulable nitrogen of blood, 456 

Occiput, Rotation of posterior, 178 

Ocular, woimds of war, 193; Intra-, cancer sarcoma of 
choroid, 312; tuberculosis, 312 

Odontoid, Fracture of, process of axis, 156 

(Edema, by means of elastometer, 60; bullosum of bladder, 
189 

OEsophagus, Roentgen-ray study of, 242; Removal of 
foreign bodies from, and bronchi with description of 
new instniments, 242; Serious, spasms in cancer of 
cardia of stomach, 362; Carcinoma of, perforating into 
right bronchus, 453 

Operation, Useless, 77; Open, for fractures, 373; New, for 
treatment of varicocele, 423; Isolation and protection 
of nerve-trunks in, for restoration of nerves, 570; 
Blood-pressures during, 574 

Operation: See also Surgery 

Operative, mortality, 67; treatment of fractures in war, 
147; treatment of brachial plexus paralysis, 157; 
Surgical significance and, treatment of enlarged and 
varicose veins of spinal cord, 281; Integral, statistics 
of surgical service at rear, 398; Routine treatment of, 
acidosis, 535; Treatment of empyema of thorax, 544; 
Extraction of intrapuhnonary projectiles, technique of 
limg surgery, 548; treatment of simple fractures, 565 

Ophthalmia, Treatment of, neonatorum, 81; Treatment of 
gonorrhoeal, 81 

Ophtiialmological errors in the field, 193 

Oral sepsis as focus of infection, 315 

Oral: See also Mouth 

Orbital, and peri-orbital fistulae, 425; Radiographs of, 
region, 425 

Orchi-epididymitis, Paratyphoidal, 422 

Orthopedic, Intraperitoneal inociilation of animals; its 
diagnostic value in, surgery, 154, 477; treatment in 
hemiplegics of long standing, 569 

Orthopedist, Backache from viewpoint of, 480 

Os calcis. Influence of, on production and correction of 
valgus deformities of foot, 265; Hereditary syphilis as 
factor in spurs on, 371; Fracture of, 372 

Osseous,Resection of humerus for fistulous osteomyelitis,f ol- 
lowed by, reproduction, 44; repair and proliferation,475 

Ossification, Retarded, as etiologic factor in traumatic 
arthritis and epiphysitis, 40; Relation of angiogenesis 
to, based upon study of calcification and ossification 
of ovary, 73 



XX 



INTERNATIONAL ABSTRACT OF SURGERY 



Osteitis, Treatment of fistulous, by polj^valent serum of 
Leclainche and Vallee, 374 

Osteo-arthritis, 472 

Osteochondritis, Syphilitic, 269 

Osteogenesis imperfecta, 472; Skeleton from, 561 

Osteomyelitis, Resection of himierus for fistulous, 44; in- 
volving the hip- joint, 473 

Osteoperiostic grafts taken from tibia to serve in recon- 
struction of bone or in repair of loss of osseous sub- 
stance, 476 

Osteotomy, Overlapping joint as substitute for cuneiform, 

43 

Otitis externa, 194 

Otitis media. Acute, 313; Vaccine treatment of chronic 
suppurative, 426; New method of opening drum 
membrane in purulent, by means of trephine, 612; 
Chronic suppurative, 612 

Otitis media: See also Ear 

Otitic origin. Pulmonary gangrene of, 135 

Otorhinology, Local anassthesia in, 231 

Ovaries, Relation of angiogenesis to ossification of, 73; 
Strangulated fallopian tube, and intestine in an in- 
fant, 74; Relation of endometrium and, to haemorrhage 
from myomatous uteri, 589; End-result of resection 
of, for microcystic disease, 301; Case of supernumer- 
ary, 502 

Ovarian, Infection of, dermoid cyst with typhoid bacillus, 
74; Labor obstructed by, cyst, 305; Managemetit of, 
tumors complicating pregnancy, labor, and the puer- 
perivun, 409; The contents of, cysts, 502; Aspects of, 
secretions, 590; Labor obstructed by, cyst, 599 

Ovaritis, Bacteriology and experimental production of, 300 

Oxygen, Apparatus for administration of gas-, 18; Use of, 
in cystography and pyelography, 511 

PAIN, Value of, jaundice, and tumor mass in differential 
diagnosis of diseases of right upper quadrant of ab- 
domen, 470; Abdominal, when associated with ab- 
normal temperature, 549 

Palliative, Radium a, 490 

Pancreatic, stone colic, 38; Behavior of, ferments in blood 
after ligature of pancreatic ducts, 286 

Pancreatitis, Serum changes and cause of death in experi- 
mental, 262; Acute haemorrhagic, 557 

Pancreopathic, Intestinal function in, conditions, 386 

Papillae, Unilateral haematuria associated with fibrosis and 
multiple microscopic calculi of renal, 510 

Papilloma of nose, 96 

Paralysis, Deformities due to infantile, operative treat- 
ment, 45; Non-operative treatment of infantile, 46; 
Iiiclusion of radial nerve in cicatrix; total radial, 49; 
Operation for correction of deformity due to obstet- 
rical, 49; Result of astragalectomy in infantile, 153; 
Operative treatment of brachial plexus, 157; Stability 
of lower extremity in, 477; Treatment of infantile, 478; 
Obstetrical, 509, 603; of intestine after resection for 
gunshot injuries, 551 

Paralytic feet, 268 

Paranasal cells, Surgical consideration of upper, 614 

Parathyroid, Physiology of, glands, 26; Function of thy- 
roid, apparatus, 134 

Parathyroidectomy, Serum changes following thyro, 238 

Paratyphoidal orchi-epididymitis, 422 

Parotid, Treatment of, tumors by radiiun, 22 

Parto-analgesia, 413 

Parturition, in minors, 177; Analgesics in, clinical and ex- 
perimental contribution, 307; Analgesics in, 411 

Pathogenesis, Anatomical and physiological subdivisions of 
duodenum with, of ulcer, 142; and treatment of pre- 
cocious, persistent, cerebral hernia, 540 



Pathogenic, Protection of, micro-organisms by living 
tissue-cells, 384 

Pathology, Anatomy and, of seminal vesicles, 90; Extirpa- 
tion of spleen in, of liver and blood, 144; of gas gan- 
grene, 383 

Pathological, bases of hydrocephalus; its surgical alle- 
viation^ 23; aspects of some problems of experimental 
cancer, 60; diagnosis of diseases of appendix, 459; 
conditions about rectal outlet, 464 

Pelvis, Drainage for pus conditions in, during pregnancy, 
601 

Pelvic, Spontaneous, peritonization in women, 455; Rela- 
tion of rectum to female, organs, 503; Etiology of, 
disease in epilepsy, 592; Diagnosis of, troubles, 593 

Penis, Amputation of, for carcinoma, 422 

Percy, Multiple acute gastric ulcers after using, cold iron 
for inoperable carcinoma, 365; Carcinoma of uterus 
treated according to, method, 588 

Perforations of various abdominal organs, 139 

Performance of operations. Injury to undiseased parts in, 
. 496 _ 

Pericolitis, Epiploon and, 388 

Perineum, Postpartum care of, 183; Operating during 
puerperium for cure of old lacerations of cervix and, 
406 

Perineal, Simple after-treatment for, wounds, 301; Total 
ischiopubic disconnection of deep, fascia to reach deep 
urethra and exteriorize the prostatovesical region, 421 

Periosteum, Artificial, for fixation of shaft fractures, 41 

Peripheral, nerves, Gunshot injuries of, syndrome of com- 
pression, 156 

Peristalsis, Normal stomach; size, position, form, tone, and 
mobility from a radiographic standpoint, 287 

Peritoneum, Gelatinoid carcinoma of, 248 

Peritoneal, adhesions; prevention with citrate solutions, 
31, 32; Antiseptic action of ether in, infections, 248; 
Inter, adhesions, 549 

Peritonealizing, Infolding and, stitch with application of 
same to broad ligament and gall-bladder, 346 

Peritonitis, Treatment of general, with obstruction, 248; 
Factors influencing mortality of, 363 

Peritonization, Spontaneous pelvic, in women, 455 

Peroral bronchoscopy. Endothelioma of right bronchus 
removed by, 547 

Perthe's disease. Causes and treatment of, 561 

Pfannenstiel incision, Nerve supply of lower abdominal 
wall as related to, 228 

Phalangeal, Arthroplasty of inter, joints, 265 

Phantom tumors, 51 

Pharmacology of novocaine, 578 

Pharynx, Carcinomata of naso, 96 

Pharyngeal, Cranio, duct tumors, 233 

Phenolsulphonephthalein, estimation of renal function, 87; 
Non-protein nitrogenous constituents of blood and, 
test in children, 483 

Plilebitis migrans, 414 

Phloridzin, Effect of, on tumors in animals, 59 

Phrenicotomy in treatment of some chronic diseases of 
lung, 360 

Physicomechanical function of faucial tonsil, 430 

Physiology of parathyroid glands, 26 

Physiological, Treatment of infected wounds by, methods, 

. 584 . 

Pillax-compression forceps for controlling haemorrhage fol- 
lowing tonsillectomy, 20 

Pineal gland, 284 

Piperazine, Uric acid solvent power of urine after admin- 
istration of, lysidin, lithiiun carbonate, and other 
alkalies, 60 

Pitultrin in labor, 81, 508 



INDEX TO SUBJECT MATTER 



XXI 



Pituitary, feeding upon growth and sexual development, 
131; Action of, extract, 159; Uses of, extract in labor, 
183; fossa and surgical methods of approaching it, 
235; Caesarean section; high forceps, 303; Influence of 
tethelin and other alcohol-soluble extractives from 
anterior lobe of, body upon growth of carcinomata in 
rats, 385; extract, 599; Results from, extract in 
obstetrics, 600 

Pituitary: See also Hypophysis 

Placenta, Miliary tubercvilosis of, with clinically latent 
tuberculosis of mother, 185; Haemorrhage associated 
with partial and complete detachment of normally 
implanted, 304; Present conditions in treatment of 
haemorrhages due to low insertion of, 599; Results of 
routine study of, 602 

Plasterers' corns and bunions, 145 

Plastic, surgery a lost art, 175; of penetrating cheek de- 
fects due to gunshot injuries, 232 

Pleura, Primary tumors of, 452; Extraction of free bullets 
from left, 452 * 

Pleural cavity, Extraction of piece of grenade from, by 
electromagnet, 359 

Pneumonia, Relation of ether, to pelvic and abdominal 
surgery, 593 

Pneiunothorax, Extraction of free bullets from left pleura 
after establishment of artificial, 452; Roentgeno- 
graphic control of, treatment of pulmonary tubercu- 
losis, 491 

Poisons, Tissue cellular protein, i6i 

PoliomyeUtic paralysis. Intradural nerve anastomosis in, 

Polygram, Use of, in gastroduodenal diagnosis, 390 

Polyposis of colon, 143 

Pons nasi, 232 

Post-hospital care of surgical patient, 59 

Postmortem caesarean section, 505 

Postoperative, ileus, 367; tetanus, 164; treatment of pep- 
tic ulcer and cholecystitis, 251; management of 
pyloric stenosis, 252; Clinical and experimental study 
of, ventral hernia, 347; Pre- and , care, 347; Absence 
of muscular tone an important etiological factor in, 
ileus, 459; treatment in rectal surgery, 536 

Postpartum care of perineiun, 183 

Postpuerperal sterility, 590 

Posture, Clinical relations of gravity, and circulation, 293 

Pott's disease treated by bone-graft, 44 

Precocious menopause in virgins, 1 76 

Pregnancy, Systolic blood-pressure in, 80; Uncontrollable 
vomiting of, 177; Histologic physiopathologic research 
on internal secretion of pancreas in, 184; Nitrogen 
metabolism during, 304; Fibroids complicating, 305; 
Pyelitis in, 309; Pyelitis of, with relation to its eti- 
ology, 409; Treatment of extra-uterine, in advanced 
periods, 407; in tuberculous, 409; Management of 
ovarian tumors complicating, labor, and puerperium, 
409; False appendicitis in, 410; Interstitial, 505; 
complicated by syphilis, 506; Blood ferments in, 506; 
toxaemia, 504, 596; Nephritic toxaemia of, 596; Aci- 
dosis complicating, 597; Care of women during, 598; 
Management of complications of, 598; Management 
of, and labor complicated by heart-disease, 598; 
Urinary diagnosis of , 601 ; Drainage for pus condition 
in pelvis during, 601; Value of Wassermann test in, 
601; Gunshot wounds in abdomen in, 507; Effects of 
nutrition of mother during, and labor on condition of 
child at birth and for first few days of life, 602 

Preservation of living red blood-cells in vitro, 52 

Pressor, Appearance of, substance in foetal hypophysis, 388 

Pressure, Symmetrical, fibromata, 472 

Primary timiors of pleura, 452 



Privilege, Waiver of, 496 

Procidentia, Vaginal hysterectomy for, 501 

Prognosis of prostatitis, 92 

Projectiles, Surgical extraction of intrapulmonary, 30, 136; 
Treatment of head injuries from, 129; Extraction of, 
from brain; use of Bergonie electrovibrator, 131; 
Operative technique of extraction of, imder guidance 
of Hirtz compass, 170; Removal of, by thoracotomy, 
359; Operative extraction of intrapulmonary, 361; 
penetrating and lodging in the heart, 361; Three 
juxtacardiac, extracted by different procedures, 361; 
in right lobe of heart after traversing cava inferiore, 
453; Traumatic stricture of urethra by, with unex- 
pected trajectory, 513 

Projectile: See also Shell, Bullet, Wound, Gunshot 

Prolapse, Treatment of genital, 405; Treatment of uterine, 
500; Etiology of uterine, and cystocele, 500; of uterus 
in nulliparous women, 589; New and simple operation 
for uterine, 591; of kidney, surgical replacement, 510 

Prolapse: See also Displacement 

Prolapsus ani. Bloodless operation for haemorrhoids and, 
261; in adults, 466 

Proliferation, Osseous repair and, 475 

Prophylaxis, Etiology and, of cancer, 50; of uterine can- 
cer, 173 

Prophylactic, use of tetanus antitoxin, 282; Result of, 
vaccination against tetanus, 382 

Prostate gland. Calcareous degeneration of, 423 

Prostatectomy, Suprapubic, 423 ; Transvesical, under local 
anaesthesia, 424; Diabetes and, 424; Internal sphinc- 
ter following, 514 

Prostatic, Urinary retention due to, obstruction, 514 

Prostatics, Calculi of vesicoprostatic region in old, 423 

Prostatitis, Prognosis of 92 

Prostato vesical. Total ischiopubic disconnection of deep 
perineal fascia in order to reach deep urethra and ex- 
teriorize the, region, 421 

Protection, Isolation and, of nerve-trunks in operations for 
restoration of nerves, 570 

Protein poisons. Tissue cellular, 161 

Protozoa, Effects of cancer tissue and normal epithelium 
on vitality of, 273 

Pruritus ani, 555 

Pseudo-appendicitis, 552; Urticaria and, 67 

Pseudohermaphrodism with abnormal function of endo- 
crine glands, 175 

Psychiatry and gynecology, 302 

Puerperium, Fatal rupture of bladder during, 305; Operat- 
ing during, for cure of old lacerations of cervix and 
perineum, 406; Management of ovarian tumors 
compUcating pregnancy, labor, and, 409 

Puerperal, Treatment of, sepsis by uterine suction and 
drainage, 305; infection, 413; Post-, sterility, 590; 
Frequency of, eclampsia, 596 

Pulmonary Surgical extraction of intra, projectiles, super- 
ficial and deep, under screen, 30, 136; Roentgeno- 
graphic diagnosis of, tuberculosis, 135; gangrene of 
otitic origin, 135; Radiographic diagnosis of metas- 
tatic, malignancy, 241; Operative extraction of 
intra, projectiles, 361; Roentgenographic control of 
pneumothorax treatment of, tuberculosis, 491; Indi- 
cations for extraction of, intra, projectiles, 547; End- 
results of pleuro, wounds by war projectiles, 548; 
Late extraction of intra, projectiles, 548 

Purgatives, Abdominal pain when associated with abnor- 
mal temperatiu-e and indication for caution in use of, 

549 
Pus, Study of, in war surgery; by pyoculture method of 
Delbet, 493; Drainage for, conditions in pelvis 
during pregnancy, 601 



XXll 



INTERNATIONAL ABSTRACT OF SURGERY 



Pustule, Malignant, treated by Baccelli's method, 378 
Pyelitis, in pregnancy, 309; of pregnancy with relation to 

its etiology, 409; Treatment of chronic colon bacillus, 

by pelvic lavage, 417 
Pyelography, New medium for, 63; Danger of, 86; 

Thorium a new agent for, 492; Use of oxygen in 

cystography with preliminary report on use of oxygen 

in, 511 
Pyelo-ureterography as aid in diagnosis of obscure surgical 

conditions of kidney and ureter, 608 
Pyloric, Operative treatment of, obstruction in infants, 

34; Ulcer of duodeno, fornix, 35; exclusion, 142; 

Perforating, and duodenal ulcers, 252; Post-operative 

management of stenosis, 252 
Pyocyaneus, Chronic general infection with bacillus, 58 
Pyogenic kidney. Urine stasis in etiology of, infections, 84 
Pyuria, causes and diagnosis, 308 



/QUININE and urea injections in hyperthyroidism, 236 

RADIUM, Treatment of parotid tumors by, 22; physics, 
62; Action of, on transplanted tumors of animals, 62; 
Therapeutic effects of, 63; treatment of uterine fibroids, 
70; achievements, 166; treatment, 288; Comparative 
value of roe,ntgen and, radiation in therapeutics, 390; 
Primary carcinoma of urethra, retention of urine 
from obstruction; restoration of function by, 421; a 
palliative, 490; Therapeutic value of, in pelvic 
cancers, 580; Actinomycosis cured with, 580; Use of, 
in field of laryngology, 581 

Radium: See also X-ray, Roentgen 

Radius, Homoplastic transplantation of boiled segment 
of, 44; Isolated fractures of head of, 473; Subluxation 
of head of, 566 

Radio-activity as therapeutic agency, 286 

Radiodiagnosis of appendicitis, 552 

Radiograms, Uses and limitations of stereoscopic, in 
diagnosis of injury to, bone, 287 

Radiographs of orbital region, 425 

Radiography, of chest in children, 166; in gunshot wounds 
of skull, 232; in diagnosis of diseases of accessory 
nasal sinuses, 428 

Radiographic, diagnosis of metastatic pulmonary malig- 
nancy, 241; Normal stomach; size, position, form, 
tone, peristalsis, and mobility from a, standpoint, 287 

Radioscopic, Operative extraction of intrapulmonary 
projectiles under, screen, 136 

Radiotherapy, Mediastinal tumor treated by, 453 

Railway injuries. Immediate and after-treatment of, 228 

Reactions of blood-vessels to certain chemicals, 488 

Rectum, Radical operation for cancer of, and rectosigmoid, 
36; Complete removal of intestinum, and colon 
pelvinum for carcinoma, 259; Spasmodic stricture of, 
464; How to qxamine, 465; Relation of, to female 
pelvic organs, 503; Diagnosis of cancer of, 554 

Rectal, Geni to-urinary symptoms arising from anal, and 
colonic diseases, 93; Ano, fistula, 259; Ischio, abscess 
from fish-bone, 259; anaesthesia, 349; Pathological 
conditions about, outlet, 464; Ano, injuries, 465; 
Postoperative treatment in, surgery, 536 

Rectovaginal septum, Adenomyoma of, 405, 594 

Recurrence of symptoms after operation for gall-stone 
disease, 467 

Reduction, immediate, of fractures, 373; of disabilities 
from wounds in war, 585 

Regeneration, Experimental researches on, and neoforma- 
tion of lymph-glands, 284; of long bones following 
infection, 472; of bone, 561 



Renal, periods of amelioration in, tuberculosis, 86; Phenol- 
sulphonephthalein estimation of, function, 87; 
Betterment in, tuberculosis, 186; Pain in, and vesical 
lesions, 188; tumors in rabbit, 274; Diagnosis and 
treatment of, tuberculosis, 310; Variations in, func- 
tion dependent on surgical procedures, 419; Experi- 
mental, sporotrichosis, 487; Diagnosis of, and ureteral 
calculi, 608 

Research, Histologic physiopathologic, on internal secre- 
tion of pancreas in pregnancy, 184; Histochemical, 
regarding function of decidua, 306; on secondary 
suture of war wounds, 494 

Resection, in projectile wounds of neck, 26; Submucous, of 
nasal septiun, 97; Partial, of motor nerves in spastic 
paralysis, 272; End-result of, of ovaries for micro- 
cystic disease, 301; of elbow in war surgery, 374; 
Paralysis of intestine after, for gunshot injuries, 551; 
Primary, in treatment of articular gunshot wounds 
with fracture, 566; of shoulder in war surgery, 566 

Respiratory tract. Foreign bodies in, 360 

Responsibility for loss of drainage tube in body of child, 497 

Results, of combined mercury-lamp and deep X-ray 
treatment of human lung tuberculosis, 61; in X-ray 
treatment of menorrhagia, dysmenorrhoea, and uterine 
myoma, 71; Method of testing antiseptics for wounds 
with some, 230; of treatment of acute appendicitis, 
368; of fractures of os calcis, 372; obtained from 
employing Carrel's method in war surgery, 494; 
Surgical considerations of splenectomy and its, 558; 
obtained by early and systematic disinfection of war 
wounds, 583; from pituitary extract in obstetrics, 600; 
of routine study of placenta, 602; End-, of nephrec- 
tomy, 607 

Resuscitation apparatus, 537 

Retention of urine. Primary carcinoma of urethra, from 
obstruction, restoration of function by radium, 421 

Retrocecal, Treatment of, appendix, 462 

Retrocession, Dysmenorrhoea, with anteflexion and, 590 

Retrodisplacement, Operation in various cases of, of 
uterus, 71, 402 

Retropharyngeal abscess discharging into left bronchus, 
196 

Retroversion, Simple method of shortening the round 
ligaments of uteru% for cure of, 296 

Rhinolith, Removal of large, 613 

Rhinology, Local anaesthesia in oto, 231 

Ribs, Cervical, 132 

Rickets, 271 

Right ventricle, Extraction of piece of shell from, 453 

Roentgen, studies after gastric and intestinal operations, 
34; treatment of deep-seated cancer, 62; treatment of 
uterine carcinoma, 174; examination of appendix, 256; 
Negative and positive, diagnosis of gall-stones, 370; 
Comparative value of, and radium radiation in 
therapeutics, 390; diagnosis of obscure lesions of 
gastro-intestinal tract, 391; deep therapy in malignant 
tumors, 391 

Roentgen-ray, diagnosis of gastric lesions, ^s'j Exact 
localization of foreign bodies by means of, 61; plates 
may be shown to juries, 171; study of oesophagus, 242; 
Gall-stone diagnosis by, 262; Gastro-intestinal 
examination by, 288; Treatment of tuberculous 
adenitis by, 389; in dental practice, 431; Sarcoma of 
kidney treated by, 607 

Roentgenographic, findings in gastro-intestinal tract, ssi 
diagnosis of pulmonary tuberculosis, 135; control of 
pneumothorax treatment of pulmonary tuberculosis, 
491 

Roentgenology, Value of, in treatment of bone and joint 
tuberculosis, 581 



INDEX TO SUBJECT MATTER 



XXlll 



Roentgenologic, examination in elimination of mouth as 

source of infection in systemic disease, 315; diagnosis 

of duodenal ulcer, 366 
Roentgenoscopic examination of stomach and duodenum, 

167 
Roentgen therapy. Filter for deep, 61; Indications for 

surgery or deep, for myomata and metropathies, 174; 

Deep, of benign and inoperable malignant conditions 

by improved technique, 491 
Rotation of posterior occiput, 1 78 
Round ligaments. Simple method of shortening the, of 

uterus for cure of retroversion, 296; Shirring of, 403; 

Shortening of, by transverse suprapubic incision, 502 
Rubber gloves. Experiments with, 347 
Rupture, Accidents due to, or abortion of simultaneous 

tubal pregnancies, 177; Fatal, of bladder during 

puerperium, 305; Traumatic, of ciliary arteries, 312; 

of uterus during labor, 411; of bladder associated 

with fracture of pelvis, 512; Spontaneous, of digestive 

tube, 550; of scar of previous caesarean section, 596 

SACR.\L autonomics, Pharmacology of ureter; action 
of drugs affecting, 311 

Saline solution. Uses and abuses of normal, 277 

Salpingectomy, Tubal sterilization; pregnancy following 
bilateral, 403 

Salpingitis, secondary to appendicitis, 74; End-results in 
cases operated for, 503 

Salvarsan treatment. Syphilitic nephritis from standpoint 
of diagnosis and, 186 

Sarcoma, of base of skull, 234; of tonsil, 430; of scapula, 
542; of kidney treated by roentgen ray, 607; of nose 
with metastases in cervical glands and in brain, 613; 
in imusual situations, 158 

Scapula, Fractures of neck of, 41; Congenital bilateral 
elevation of, 46; Congenital elevation of, 147; Sar- 
coma of, histological diagnosis made by study of 
blood aspirated from pulsating portion of tumor, 542 

Scarlatina, Etiology of surgical, 51 

Scars, Treatment of, 484 

Scissors, Combination needle-holder and ligature, 129 

Sclayer's kidney test, Intravenous injections of lactose 
without reaction, 87 

Sclerocorneal trephining in glaucoma, 515 

Sclerodermia associated with Graves' disease benefited by 
implantation of human thyroid into bone-marrow, 
238 

Sclerotics, Blue, their relation to multiple fractures in 
childhood, 472 

Scoliosis, 155; Treatment of, 480 

Scopolamine and narcophine, Shockless surgery with help 
of paravertebral anaesthesia with, 231 

Scopolamine-morphine anaesthesia in labor, 507 

Scrotal affections, Inguinal incision for intra, 191 

Secondary, closing of wounds, 65; Researches on, suture 
of war wounds, 494; union of war wounds by first 
intention, 494 

Secretions, Aspects of ovarian, 590; Nature of bactericidal 
property of vaginal, 592 

Secretory disorders. Diagnosis of internal, 573 

Section, Anatomoclinical study of total, of spinal cord, 47; 
Complete, of left radial nerve; nerve-suture, 49; 
Caesarean, 407 

Segmental caesarean operation, 408 

Semicircular apparatus of ear and cerebellar localization 
as diagnostic key to intracranial conditions, 194 

Seminal, Anatomy and pathology of, vesicles, 90; Treat- 
ment of non-tuberculous inflammations of, duct, 91; 
Tuberculosis of, vesical and epididymis, 91; vesi- 
culitis, 513 



Sensitized serums, Immunity conferred by transfer of 
immune and mixed immune and, 574 

Sepsis, Treatment of puerperal, by uterine suction and 
drainage, 305 

Septic, Physics of surgical dressing with use of imper- 
meable material over, wounds, 17; Sodium hypo- 
chlorite in treatment of, wounds, 66; Treatment of 
wounds with drainage, 292; Treatment of, war wounds 
by abstention, 583 

Septum, Submucous resection of nasal, 97; Deviations of 
nasal, and submucous operation, 613 

Sera, Antagonistic action of negative, upon Wassermann 
reaction, 276 

Serum, Treatment of gonococcic conjunctivitis by ante- 
gonococcic, 94; changes following thyropara thy- 
roidectomy, 238; changes and cause of death in 
experimental pancreatitis, 262; Treatment of fistulous 
osteitis by polyvalent, of Leclainche and Vallee, 374; 
Immunity conferred by transfer of immune and 
mixed immune and sensitized, 574 

Serotoxin of Jobling, 276 

Seven-glass urinary test, 418 

Sex-gland implantation, 424 

Sexual development. Pituitary feeding upon growth and, 

131 

Sheet rubber superior to gauze sponges in abdominal 
operations, 535 

Shirring round ligaments, 403 

Shock, Cytological analysis of, 578; -less surgery with 
help of paravertebral anaesthesia with scopolamine 
and narcophine, 231 

Shortening, Simple method of, round ligaments of uterus 
for cure of retroversion, 296; of round ligaments by 
transverse suprapubic incision, 502 

Shoulder, Resection of, in war surgery, 566 

Shrapnel bullet. Extraction of, from third lumbar vertebra, 
570 

Sialodochitis, Sialolithiasis and, in childhood, 197 

Siamese twins, 415 

Sigmoid, Radical operation for cancer of rectum and 
recto, 36; Acute angulation and flexure of, 463 

Sigmoidoscopic, Position for, work, 463 

Sinus, thrombosis in compression, 130; Lateral, thrombosis, 
194; Bacteriology of nasal, disease, 516; Brain 
abscess from chronic suppuration of frontal, 614; 
Diagnosis and treatment of inflammatory affections 
of nasal accessory, 96, 427; Treatment of diseases of 
accessory of nose, 314; Malignant disease of nose or 
accessory, advantages of operating through face, 427; 
Radiography in diagnosis of diseases of accessory nasal, 
428; Bismuth paste in chronic suppurative, and em- 
pyema, 545 

Sinusitis, Circumscribed purulent leptomeningitis due 
to frontal, 354 

Skeleton from osteogenesis imperfecta, 561 

Skiagraphy, Diagnosis of fracture by physical examination 
versus, 263 

Skill and care required, 171 

Skull, Radiography in gunshot wounds of, 232; Sarcoma 
of base of, 234; Pneumococcic and meningococcic 
meningitis after fracture of base of, 353; Thyroid 
tumors of bones with reference to non-malignant 
pulsating tumors of, 354 

Sluder method of tonsil enucleation, 196, 430 

Snare and bullet. New hasmorrhagic operation, 261 

Sodium, hypochlorite in treatment of septic wounds, 66; 
Experimental study of use of, citrate in transfusion 
of blood, 379; Experimental study of additive and 
antagonistic actions of, oxalate and salts of magnesium 
and calcium in the rabbit, 387 



XXIV 



INTERNATIONAL ABSTRACT OF SURGERY 



Soldier's foot and treatment of coijimon deformities of 

foot, 479 
Solutions, Simple method of giving, by bowel, 229 
Spasm, Tetanus-like, localized to wounded limb, 289 
Spasmodic stricture of rectum, 464 

Spastic paralysis. Partial resection of motor nerves in, 272 
Sphagnum moss. Methods of preparing, as surgical 

dressing, 228 
Sphincter, Internal, following prostatectomy, 514 
Spine, Injuries of lower, 155; Coagulation massive and 
xanthochromie occurring in tuberculosis of cervical, 
156; Congenital anterior curvature of, 270; Gunshot 
wounds of, 270; Treatment of gunshot wounds of, 271; 
Handling of children with tuberculosis of, while 
under influence of anaesthetic, 480; Treatment of 
caries of, by bone-transplantation, 570 
Spina bifida, 47 

Spinal, anaesthesia, 19; Bone-grafting for, conditions, 47; 
Anatomoclinical study of total section of, cord, 47; 
Visceroptosis to, lesions, 154; anaesthesia, 230; Gun- 
shot wounds and injuries of, cord, 271; Surgical 
significance and operative treatment of enlarged and 
varicose veins of, cord, 281; Injuries of, cord with 
gunshot injury of cord at fourth cervical vertebra and 
successful removal of projectile, 377; Manual expres- 
sion of bladder in, injury, 421; anaesthesia, 446; 
Technical features of laminectomy for, disease and 
injury based on 150 spinal operations, 569 
Spleen, Association of, with liver and its relation to certain 
conditions of blood, 38; Extirpation of, in pathology 
of liver and blood, 144; Concretions of, 144 
Splenectomy, for wounds, 370; Technique of, 557; Treat- 
ment by, of splenomegaly with anaemia associated 
with syphilis, 557; Surgical considerations of, and its 
results, 558; Metabolism studies before and after, in 
pernicious anaemia, 560 
Splenectomized, Lethal dose of arsenic for, mice, 580 
Splints, Fracture, 232; for drop-wrist, 475 
Splinting, Device for intramedullary fracture, 43 
Spondylitis, Cervical, of doubtful nature, 155; Experience 

with Albee operation for, tuberculosis, 477 
Spontaneous pelvic peritonization in women, 455 
Sporotrichosis, Experimental renal, 487 
Sprains and sprain-fracture of the wrist-joint, 564 
Spurs, Hereditary syphilis as factor in, on os calcis, 371 
Standardization, Fracture records; effort towards, 146 
Staphyloma, Operative treatment of partial of cornea and 

fistula of cornea, 61 1 
Stasis, Intestinal, 256; High intestinal, 458; Hernia in 
relation to intestinal, 455; Experimental colonic, 462 
Steam, Superheated, in treatment of superficial cancer, 572 
Stenosis, Adjustment of intra-uterine stem versus dila- 
tation to overcome, of cervical canal, 173; Congenital, 
of duodenum in adult, 456 
Stercobilin, 387 
Sterility, in female, 406; Causes and treatment of, in 

women, 503; Postpuerperal, 590 
Sterilization, Tubal, 403; of war wounds, 493 
Stillbirths, Bacteriologic study of causes of some, 509 
Stomach, Aids in diagnosis of surgical conditions of, 
characteristic X-ray appearance of syphilitic hour- 
glass in contrast to simple ulcer and cancer, 32; 
Treatment of diseases of, 34; Acute dilatation of, 
complicating operations on extremities, 127; Roent- 
genoscopic examination of, and duodenum, 167; Ionic 
concentration of gastric contents in some, diseases, 
249; Normal, from radiographic standpoint, 287; 
Serious cesophagic spasms in cancer of cardia of, 362; 
Occult bleeding in ulcus ventriculi and, carcinoma, 
364; Surgery of posterior wall of, 365; Perforated 



ulcers of, and duodenum, 550; Diagnosis of cancer of, 

551 

Stomach: See also Abdomen 

Stone, Pancreatic, colic, 38 

Strangulation, Retrograde, 364 

Strangulated fallopian tube, ovary, and intestine in an 
infant, 74 

Streptococcus mucosus capsulatus infection of mastoid 
bone, 612 

Stricture, Ureteral, 87; Congenital, of urethra, 421; 
Traumatic, of urethra by projectile, 513 

Strumitis, Eberthian, 541 

Stumps, After-treatment of amputation, 268; Aperiosteal, 
and its care, 476 

Subacromial bursitis. Deposit in supraspinatus muscle 
simulating, 41 

Subluxation of head of radius, 566 

Submaxillary, Calculi in, gland and Wharton's duct, 21 

Submucous, Improved, operation, 98; resection of nasal 
septum, 97; Deviations of nasal septum and, opera- 
tion, 613 

Subungual exostosis, 40 

Suction, Curved lines of, 604 

Supernumerary, ureter, 311; Ovaries, 502 

Suppurations, Surgical treatment of, in posterior medias- 
tinum, 545 

Suppurating, Treatment of, wounds in war, 66 

Suppurative, haematoma of iliac fossa, 277; Treatment of, 
appendicitis, 462; Chronic, mastoiditis accompanied 
by intracranial pressure, 515; Therapeutics of chronic 
non-tuberculous, bronchiectasis, 546; Chronic, otitis 
media, 612 

Suprapubic prostatectomy, 423 

Suprasymphyseal, Transperitoneal, caesarean section on 
account of scariform growth in vagina, 304 

Surgeon's responsibility to economics of the hospital, 585 

Surgery, Experimental, of mediastinum, 59; Lung, 136; 
Plastic, 175; Acidosis in, 275, 573; Time in, 283; in 
war, 392; Influence of S3^hilis upon 573; Motion 
study in, 586 

Surgical, Non-adhering, gauze, 17; Physics of, dressing, 17; 
Etiology of, scarlatina, 51; Methods of preparing 
sphagnum moss as, dressing, 228; uses of celluloid, 
231; Pituitary fossa and, methods of approaching it, 
235; Acute, abdomen, 245; Care of abdominal, cases, 
247; Management of, disorders of digestion, 255; 
aspects of painful back, 272; War, interventions, 397; 
Integral operative statistics of, service at rear, 398; 
treatment of nephritis, 417; Variations in renal 
function dependent on, procedures, 419; Thoracic 
disease; the status of, therapy, 543; Vaccine treat- 
ment in, cases, 574; Treatment of, tuberculosis with 
general carbon arc light bath, 582 

Suspension, Treatment of fractures by, and extension, 

474 

Suture, Complete nerve sections treated by, 273; Intra- 
dermic, 346; of nerves and alternative methods of 
treatment by transplantation of tendon, 375; Nerve-, 
377; Advantages of separate, of mucous membrane 
in gastric surgery, 551 

Sweet, X-ray localization of foreign bodies in eye by, 
method, 611 

Symmetrical pressure fibromata, 472 

Sympathetic system in diagnosis of abdominal diseases, 400 

Synovial sac, Treatment of purulent arthritis of knee by 
arthrostomy or marsupialization of, 40 

Syphilis, of internal genital organs in female, 74; in its 
relation to obstetrics, 82; Hereditary, as factor in 
spurs on os calcis, 371; Necessity for early diagnosis 
and continuous treatment in congenital, 426; Preg- 



INDEX TO SUBJECT MATTER 



XXV 



nancy complicated by, 506; Treatment by splenectomy 
of splenomegaly with anaemia associated with, 557; 
Influence of, upon surgery, 573; Significance of, in 
obstetrics, 603 
Syphilitic, Aids in diagnosis of surgical conditions of 
stomach with characteristic X-ray appearance of, 
hour-glass in contrast to simple ulcer and cancer, 32; 
Unrecognized, lesions surgically operated as cancer or 
local tuberculosis, 67; osteochondritis, 269 

TALIPES equinus through myositis of triceps, 154 
Tarsus, Arrested development of carpus and, 263 

Technique, Operative, of extraction of projectiles under 
guidance of Hirtz compass, 170; by which conserva- 
tism is possible in diseases of adnexa, 174; of enucle- 
ation thyroidectomy, 238; at Jewish Maternity 
Hospital and its results, 307; of tracheotomy in 
adult, 545; of splenectomy, 557 

Tendon-transplantation, 375; in infantile paralysis, 45 

Tenotomy of inferior oblique muscle, 313 

Teratoid tumor of anterior region of neck in human 
foetus at term, 541 

Teratomata of brain, 540 

Test, Quantitative, of Abderhalden reaction, 78; Seven- 
glass urinary, 418 

Testicle, Varicocele operated upon by high suspension of, 
191; Treatment of undescended, 422; Treatment of 
gunshot wounds of, 422 

Tetanus, 577; Delayed, 58; Treatment of ,58; Post-operative, 
164; as a surgical complication in present war, 282; 
Prophylactic use of, antitoxin, 282; Iodine in, 282; 
Mental symptoms complicating acute, during treat- 
ment by carbolic injections, 282; spasm localized to 
wounded limb, 289; Localized, 381; Result of prophy- 
lactic vaccination against, 382; Present status of 
magnesium sulphate in treatment of, 383 

Tethelin, Effects of, 286; Influence of, upon growth of 
carcinomata in rats, 385 

Therapeutic, effects of radium, 63; Radio-activity as, 
agency, 286; Method of action of antiseptics and pro- 
cedures for determination of their value, 348; Com- 
parative value of roentgen and radium radiation in, 
390; of non-tuberculous suppurative bronchiectasis, 
546; value of radium in pelvic cancers, 580 

Thigh, Treatment of fractures of, in war surgery, 371 

Thorax, Gimshot wounds of, 28; Recent progress in opera- 
tive treatment of, 544; Chylo, 544; Surgical therapy 
of diseases of, 543 

Thoracotomy, Removal of projectiles by, 359 

Thorium, a new agent for pyelography, 492 

Throat, Significance of haemorrhage in operations on nose 
and, 314; Infections of, as primary foci for secondary 
infections, 611 

Throat: See also Larynx 

Thrombin, Pro-, and anti-thrombin factors in coagulation 
of blood, 161 

Thrombosis, Venous, and embolism, 54; Sinus, in com- 
pression, 130; Lateral sinus, 194; Treatment of, 575 

Thrombo-angiitis obliterans; Conservative treatment of 
gangrene of extremities due to, 53; Operative treat- 
ment, of 55 

Thymus, Enlarged, in infancy, 29; and its tumors, 240; 
Alterations of endocrine glands, especially the, and 
of blood following vagotomy, 490 

Thymic disturbances in adult, 135 

Thyroid, Tonsillar endamoebiasis and, disturbance, 26; 
tumor in sea bass, 237; Carcinoma of, in fish, 237; 
Sclerodermia associated with Graves' disease and 
benefited by implantation of human, into bone- 
marrow, 238; tumors of bones with non-malignant 



pulsating tumors of skuU, 354; Anatomy and surgery 
of, glands, 449; Functional significance of mitochon- 
dria in toxic, adenomata, 450 

Thyroidectomy, Technique of enucleation, 238 

Thyroidism, Blood-pressure in dys-, 134 

Thyroidpara thyroid. Function of, apparatus, 134 

Thyroidparathyroidectomy, Senun changes following, 238 

Thyrotomy, Partial excision of thyroid cartilage as 
alternative to, in malignant disease of vocal cord, 315 

Tibia, Fracture of tuberosities of, 372 

Tissue, cellular protein poisons, 161; Reactions between 
bacteria and animal tissues under conditions of 
artificial cultivation with bactericidal action in, 
cultures, 163 

Toluol as a storing fluid for catgut, 128 

Tongue, Tuberculosis of, 98; Lacing the lingual artery for 
secondary haemorrhage of, 162; Cancer of mouth 
and, 517 

Tonsil, operation under local anaesthesia, 98; Removal of, 
and adenoids in diphtheria carriers, 98; question, 195; 
Treatment of, 195; Sluder method of, enucleation, 
196; Sarcoma of, 430; Physicomechanical function 
of faucial, 430; enucleations with Beck-Pierce tonsil- 
lectome, 431 

Tonsillar, endamoebiasis and thyroid disturbance, 26; 
Secondary haemorrhage, 516 

Tonsillectomy, Pillar-compression forceps for controlling 
haemorrhage following, 20; Age in, 98; Abscess of lung 
after, 196, 516; According to Sluder technique, 430; 
as a new method of tonsil eradication, 516 

Tonsillitis, Cerebral abscess due to suppurative, 131 

Tonsilloscope, 429 

Torula infection in man, 400 

Toxaemia, Pregnancy, 504,596; Nephritic, of pregnancy, 596 

Toxicity, Inhibition of, of anaesthetics for nephrophatic 
kidney, 128 

Toxin, Sero, of Jobling, 276 

Trachea, War injuries of larynx and, 360 

Tracheotomy, Technique of, in adult, 545; Removal of 
fragment of, tube from lung six years after inspiration. 

Transfusion, 483; Reaction following blood, by syringe 
cannula system, 55; Preservation of living red blood- 
ceUs in vitro, of kept cells, 56; Relation of haemoly- 
sis in, of babies with mothers as donors, 56; Contin- 
uous, in production of immunity, 161; Indications for 
blood, 278, 279; Testing donors for, of blood, 279; 
Blood-, in treatment of post-haemorrhagic anaemia 
and haemorrhagic diseases, 279; Direct blood-, with 
Kimpton-Brown tubes, 280; Blood-, 379; Experimen- 
tal study of use of sodium citrate in, of blood by direct 
and indirect methods, 379; Blood-, in haemorrhage of 
newborn, 604 
Transitional, Origin and status of, white blood-ceU, 160 
Transperitoneal suprasymphyseal caesarean section on ac- 
count of scariform growth in vagina, 304 
Transplants, Repair of losses of frontal substance by means 

of cartilaginous, 22 
Transplantation, Bone-, in nose deformities, 21; Homo- 
plastic, of boiled segment of radius, 44; Tendon-, in 
infantile paralysis, 45; of bone in ununited fractures 
of shaft of humerus, 264, 568; of tissue, 267; Tendon- 
375; Suture of nerves and alternative methods of 
treatment by, of tendon, 375; Important points in 
bone-, 476; of bone and some uses of bone-graft, 568 
Transplanted, Action of radixun on, tumors of animals, 62 
Transverse process. Fracture of lumbar vertebras and, 155 
Transverse suprapubic incision. Shortening of round liga- 
ments by, 502 
Transvesical prostatectomy under local anaesthesia, 424 



XXVI 



INTERNATIONAL ABSTRACT OF SURGERY 



Trapezius, Repair of breach of, and splenius with cicatrix 
adhering to cervical vertebrae, 374 

Traumatisms, Indirect, of lung due to nearby explosion of 
large war projectiles, 361 

Traumatic, aneurisms, 380; Treatment of, arthritis of 
knee, 567 

Treatment, Vaccine, 276; Radium, 288; Physical, for dis- 
abled soldiers, 291; Principles of, and their application 
to wounds, 292; Painless, rational, and economic, of 
wounds, 292; of thrombosis, 575; of wounds in civil 
practice, 577; of surgical tuberculosis with general 
carbon arc light bath, 582 

Trephine, New method of opening drum membrane in 
purulent otitis media by means of, 612 

Triangles, Ligature of lingual artery in, of Beclard and 
Pirogoff, 197 

Triceps, Talipes equinus through myositis of, 154 

Trifacial, Diagnosis and treatment of, neuralgia, 537 

Trigonitis, Chronic, 31 1 

Trophic element in origin of gastric ulcer, 140 

Tube, Strangulated fallopian, ovary and intestine in an 
infant, 74; Surgical treatment of gonorrhoeal, infec- 
tion with quarantine pack, 77 

Tubal, Accidents due to rupture or abortion of simultan- 
eous, pregnancies, 177; sterilization, 403 

Tuberculosis, Results of combined mercury-lamp and deep 
X-ray treatment of human lung, 61; Experimental 
grounds for treatment of lung, by X-rays, 61; Un- 
recognized syphilitic lesions surgically operated as 
cancers or as local, 67; Periods of amelioration in re- 
nal, 86; of seminal vesical and epididymis, 91; Diag- 
nosis and prognosis of urogenital, 92; of the tongue, 
98; Roentgenographic diagnosis of pulmonary, 135; 
Coagulation massive and xanthochromie occurring 
in, of cervical spine, 156; Miliary, of placenta with 
clinically latent tuberculosis of mother, 185; Better- 
ment in renal, 196; Diagnosis of genito-urinary, 192; 
of mammary gland, 240; Diagnosis and treatment of 
renal, 310; Ocular, secondary to industrial accident, 
312; of breast, 358; Necessity for operation in joint, 
475; Experience with Albee operation for spondylitis, 
477; Handling of children with, of spine, 480; Treat- 
ment of surgical, with carbon arc light bath, 582 

Tubercular baciUaemia, 388 

Tuberculous, Treatment of non-, inflammations of seminal 
duct, 91; Non-surgical treatment of, glands, 133; 
Changed character of later lesions occurring in healed, 
joints, 145; Treatment of chronic non-, empyema, 240; 
Treatment of, adenitis by roentgen rays, 389; Preg- 
nancy in, 409; Treatment of abscesses in, diseases of 
joints and bones, 475; Autogenous bone-splints in 
fractures and, spines, 568 

Tuberosities, Fracture of, of tibia, 372 

Tumors, Treatment of parotid, by radium, 22; Localiza- 
tion of cerebellar, 24; of carotid body, 25; Classifica- 
tion of, 51; Phantom, 51; Effect of phloridzin on, in 
animals, 59; Action of radium on transplanted, of 
animals, 62; Cauterization and fulguration of bladder, 
89; Cranio-pharyngeal duct, 233; Thyroid, in sea bass, 
237; Thymus and its, 240; Renal, in rabbit, 274; 
immunity, 274; growth in animals with spontaneous 
tumors, 158; Thyroid, of bones, 354; of hypothalamic 
region of middle brain, 355; Localization of cerebellar, 
355; Chemical study of, 378; Roentgen deep therapy 
in malignant, 391; Free, diagnosis, 399; Management 
of ovarian, complicating pregnancy, 409; Malignant 
of right kidney in child, 416; Rare mammary, 452; 
Primary, of pleura, 452; Mediastinal, treated by radio- 
therapy, 453 ; Pathology of large intestine with radical 
operation for colonic, 553 



Turbinate, Galvanocautery operation for lower, 97 
Twilight sleep, 183 
Twins, Siamese, 415 

Typhoid, Infection of ovarian dermoid cyst with, bacil- 
lus, 74 

ULCERS, Aids in diagnosis of surgical conditions of 
stomach with especial reference to characteristic 
X-ray appearance of syphilitic hour-glass in contrast 
to simple, and cancer, 32; Gastric, following removal 
of adrenals, 33; of duodenopyloric fornix, 35; of je- 
junum, 35; Trophic element in origin of gastric, 140; 
Etiologic relationship existing between gastric, and 
gastric cancer, 140; Treatment of gastric, 141; Ana- 
tomical and physiological subdivisions of duodenum, 
with pathogenesis of, 142; Cause of gastric, 250; 
Traumatic gastric, 251; Postoperative treatment of 
peptic, and cholecystitis, 251; Perforating pyloric and 
duodenal, 252; Chronic gastric and duodenal, 253; 
Surgical treatment of gastric and duodenal, 254; 
Duodenal, with special reference to its X-ray diagno- 
sis, 254; Multiple acute gastric, after using Percy's 
cold iron for inoperable carcinoma, 365; Roentgeno- 
logic diagnosis of duodenal, 366; Chronic, of duo- 
denum, and its gastric repercussion, 366; Perforated, 
of stomach and duodenum, 550; Excision versus 
gastro-enterostomy in treatment of gastric, 551 

Ulcus ventriculi. Occult bleeding in, and stomach carci- 
noma, 364 

Ultraviolet rays. Treatment of naevus flammeus and allied 
conditions by filtered, employing the compression 
method of application, 491 

Umbilical hernia, End-Results in, operations, 249 

Undescended, Treatment of, testicle, 422 

Unilateral haematuria, 86 

Ununited, Malunited and, fractures, 473 

Urachus, Permeability of, 512 

Ureter, Non-surgical infection of kidneys and, 84; Phar- 
macology of, action of epinephrin, ergotoxin, and 
nicotine, 165; Multiple, with hydronephrosis, 189; 
Supernumerary, 311; Pharmacology of, action of 
drugs affecting sacral autonomics, 311; Pyelo-ureterog- 
raphy as aid in diagnosis of obscure surgical con- 
ditions of kidney and, 608 

Ureteral, Stricture, 87; Diagnosis of, calculus, 419; Giant, 
calculus; anomalous development of genito-urinary 
tract, 510; calculi, 607; Diagnosis of renal and, calculi, 
608 

Ureterography, Pyelo-, as' aid in diagnosis of obscure 
surgical conditions of kidney and ureter, 608 

Urethra, Double, with operation, 90; Venous autoplasty 
of traumatized, 191; Primary carcinoma of, retention 
of urine from obstruction; restoration of function by 
radium, 421; Congenital stricture of, 421; Traumatic 
stricture of, by projectile with unexpected trajectory, 
513; Injuries of bladder and, in war, 609 

Urethral, Gonorrhoeal infection of, glands, 190; Diagnosis 
and treatment in obscure, pain, 191 

Urethritis, Chronic, in women diagnosis and treatment 
in obscure urethral pain, 191 

Uric acid solvent power of urine after administration of 
piperazine, lysidin, lithium carbonate, and other 
alkalies, 60 

Urine, Uric acid solvent power of, after administration of 
piperazine, lysidin, lithium carbonate, and other al- 
kalies, 60; Demonstrating bacteria in, by centrifuge; 
relative value of examinations by culture or stained 
sediment, 84; stasis in etiology of pyogenic kidney 
infections, 84; Hexamethylenamine as urate solvent 
and diuretic, and its effect on reaction of, 92 



INDEX TO SUBJECT MATTER 



xxvu 



Urinary, Problems in X-ray diagnosis of, calculi, 89; 
Hexamine as, antiseptic, 189; Diagnosis of genito-, 
tuberculosis, 192; Seven-glass, test, 418; Herniae of, 
bladder, 512; retention due to prostatic obstruction 
514; diagnosis of pregnancy, 601 

Urogenital, War injuries of, system, 85; Diagnosis and 
prognosis of, tuberculosis, 92 

Urticaria and pseudo-appendicitis, 67 

Uterus, Double, in its relation to diagnosis and treatment, 
71; Operation for retrodisplacement of, 71; Removal 
of troublesome useless, 72; Operation for posterior 
displacement of, 296; Operation in various cases of 
retrodisplacement of, 402; Rupture of, during labor, 
411; Essential haemorrhage of, 499; Red myoma of, 
499; Treatment of backward displacements of, 500; 
Cancer of, 588; Carcinoma of, treated according to 
Percy method, 588; Prolapse of, in nuUiparous women, 

589 
Uterine, Heat as method of treatment in inoperable, car- 
cinoma, 69; Radium treatment of, fibroids, 70; Lower, 
segment; its origin and boundaries, 79; Prophylaxis 
of, cancer, 1 73 ; Roentgen treatment of, carcinoma, 1 74; 
Treatment of puerperal sepsis by, suction and drain- 
age, 305; X-ray treatment of, myomata, 402; Uni- 
lateral polypiform cedematous elongation of, cervix, 
499; Treatment of, prolapse, 500; Intra-, crying, 508; 
Etiology of, prolapse and cystocele, 500; New and 
simple operation for, prolapse, 591 

WACCINE, treatment, 276; treatment of chronic sup- 
' purative otitis media, 426; therapy and other treat- 
ment in acne vulgaris and furunculosis, 481; treat- 
ment in surgical cases, 5 74 

Vaccination, Result of prophylactic, against tetanus, 382 

Vaginal, hysterectomy for procidentia, 501; hysterectomy, 
501 ; Nature of bactericidal property of, secretion, 592; 
Adenomyoma of recto, septimi, 594 

Vaginitis, Report of committee on, 403 

Vagitus uterinus, 178 

Vagotomy, Alterations of the endocrine glands, especially 
the thymus and of blood following, 490 

Valgus, Influence of os calcis on production and correction 
of, deformities of foot, 265; Autogenous bone-graft 
pin in treatment of painful flat-foot and paralytic, 
266; Hallux, 376 

Varicocele, Vaginal hydrocele operated upon by inguinal 
route, operated upon by high suspension of testicle, 
191; New operation for treatment of, 423 

Varicose veins. Surgical significance and operative treat- 
ment of enlarged and, of spinal cord, 281 

Vascular injuries. Auscultation in diagnosis of, accompany- 
ing gunshot wounds, 281; Experience with, 381 

Veins, Gunshot arteriovenous aneurism in which the sac 
was situated on side opposite the, 280; Wounds of, 381 

Venous autoplasty of traumatized urethra, 191 

Vertebra, Dislocation of first cervical, produced by manip- 
ulation, 48; Injuries of spinal cord with gunshot in- 
jury of cord at fourth cervical, and successful removal 
of projectile, 377; Extraction of shrapnel buUet from 
third lumbar, 570; Fracture of lumbar, and transverse 
processes, 155; Repair of breach of trapezius and splen- 
ius with cicatrix adhering to cervical, 374 

Vertebral metastatic carcinoma primary in breast, 3 76 

Vertex presentation. Late conservative caesarean operation 
with, for cicatricial atresia of vagina, 504 

Vesical fistula due to permanent foreign body in bladder, 1 89 

Vesical, Pain in renal and, lesions; its characteristics; 
anomalies and misguiding manifestation, 188; drain- 
age; historical review and presentation of new ap- 
paratus, 420 • 



Vesicoprostatic, Calculi of, region in old prostatics, 423 

Vesiculitis, Seminal, 513 

Vestibular, New method of examining the, labyrinth, 515 

Visceral crises in angioneurotic cedema, 245 

Visceroptosis, 471; Rdle of, in arthritis deformans, 145; 
Relation of, to spinal lesions, 154; Incidence of, 262 

Vocal cord. Partial excision of thyroid cartilage as an alter- 
native to thyrotomy in malignant disease of, 315 

Volvulus, 457; Gastric, in hour-glass stomach of congenital 
malformation, 249 

Vomiting, Uncontrollable, of pregnancy, 177; Uncontroll- 
able, of lactation, 602 

\A/.AIVER of privilege, 496 

' » War, treatment of infected joints in, 42 ; Injuries of the 
large bloodvessels in, 57; Functional status of ampu- 
tation stumps in, 148; Tetanus; a surgical complica- 
tion in the present, 282; Gas gangrene in present, 289; 
Organization and problems of, hospital, 293; Cranial 
wounds in, surgery, 353; Indirect traumatisms of 
lung due to nearby explosion of large, projectiles, 
361; Wounds of abdomen by, projectiles, 363; Treat- 
ment of fractures of thigh in, surgery, 371; Resections 
of elbow in, surgery, 374; Surgery in, 392; surgical 
interventions, 397; Study of pus in, surgery, 493; 
Gaseous gangrene in, surgery, 493 ; Cranial wounds by, 
projectiles at front, 538; Treatment of cranial wounds 
by, projectiles, 539; End-results of pleuropulmonary 
wounds, by projectiles, 548; Frozen limbs and their 
treatment in present, 561; Resection of shoulder in, 
surgery, 566; Treatment of bladder injuries by, 
projectiles, 610; Injuries of bladder and urethra in, 
610; Results obtained from employing Carrel's method 
of, surgery, 494 

War fractures, 145; Operative treatment of, 147 

War injuries, of urogenital system, 85; of jaws and face, 
130J 350; of larynx and trachea, 360; Considerations 
on, 493 

War wounds. Aneurisms of, 56; Rules relative to treatment 
of suppurating, 66; Abdominal, surgery, 137; Treat- 
ment of, 168; of nose, nasal fossae, and accessory 
cavities, 195; Partial amputation of foot for gunshot, 
375; Sterilization of, 493; Secondary union of, by 
first intention, 494; Researches on secondary suture 
of, 494; Treatment of septic, by abstention, 583; 
Results obtained by early and systematic disinfection 
of, 583; Treatment of infected suppurating, 584; 
Reduction of disabilities from, 585 

Warfare, wounds of chest in, 27; Operations for cranio- 
cerebral wounds of modem, 448 

Wassermann, Antagonistic action of negative sera upon, 
reaction, 276; Routine, reaction in hospital obstetrics, 
415; Value of, test in pregnancy, 60 1 

Wharton's duct. Calculi in submaxillary gland and, 21; 
Calculus of, 353 

Wounds, Physics of surgical dressing of, with reference to 
the use of impermeable material over septic wounds, 
17; Resection in projectile, of neck, 26; of chest in 
warfare, 27; Gunshot, of chest, 239; Gunshot, of 
thorax, 28 ; Aneurisms of war, 56 ; Epicrises in, aneur- 
isms, 5 7 ; Gunshot, of soft parts, 63 ; Secondary closing 
of, 65; Treatment of gunshot, 65; Sodium hypochlor- 
ite in treatment of septic, 66; Rules relative to treat- 
ment of suppurating, in war, 66; dressings, 127; 
Gunshot retention, 167; Gunshot, in upper limbs, 167; 
Treatment of, in war, 168; Ocular, of war, 193; of 
nose, nasal fossae, and accessory cavities in time of 
war, 195; Method of testing antiseptics for, 230; 
Bacteria of gangrenous, 283; Effects of tethelin in 
healing of, 286; Principles of treatment and their 



xxvm 



INTERNATIONAL ABSTRACT OF SURGERY 



application to, 292 ; Treatment of septic, with drainage, 
292; Painless, rational, and economic treatment of, 
292; Simple after-treatment for perineal, 301; Con- 
tinuous irrigation of, in field, 347; Very extensive 
shell, of face, 350; Articular gunshot, 363; Splenec- 
tomy for, 370; Immediate treatment of articular, in 
field ambulance, 371; of veins, 381; Treatment of, by 
method of Carrel, 397; Treatment of gunshot, in 
bladder, 420; Treatment of gunshot, of testicle, 422; 
Origin and structure of fibrous tissue formed in, heal- 
ing, 487; Sterilization of war, 493; Clinical, cytologi- 
cal, and therapeutical study of, of chest in ambulance 
at front, 542; Process of repair in, of small intestine, 
552; Treatment of wounds in civil practice, 577; 
Dressing of, 583; Treatment of septic war, by absten- 
tion, 583; Treatment of infected, by physiological 
methods, 584; Treatment of infected suppurating 
war, 584; Reduction of disabilities from, in war, 
585; Tetanus-like spasm localized to limb, 289 

Wounds of abdomen. Gunshot, 30; in surgery, 137; 
Evolution of treatment of, in ambulance at front, 
138; and their treatment, 138; Penetrating, 242, 243, 
244; Symptoms and complications of gunshot, 246; 
Treatment of penetrating, in ambulance, 363; by 
war projectiles, 363 

Wounds of cranium, Gunshot, 20; Gunshot, 232; in war 
surgery, 353; Grave accidents of late appearance in 
craniocerebral wounds of war, 354; Craniocerebral 
and, 354; Operations for, of modern warfare, 448; 



by war projectiles at front, 234; operations, 538; 

Treatment of, at front, 539; Treatment of, by war 

projectiles, 539; Process of cicatrization of open, 541 
Wounds of spine, Gunshot, 270; Treatment of, 271; 

Gunshot injuries and, cord, 271 
Wounds: See also Military 
Wrist, Splint for drop-, 475; Springs and sprain-fracture 

of the, -joint, 564 

VANTHOCHROMIE, Coagulation massive and, oc- 
-* *■ curring in tuberculosis of cervical spine, 156 
Xenomenia, Compensatory menstruation, memmes 

devii, 70 
X-ray, Aids in diagnosis of surgical conditions of stomach 
with especial reference to characteristic, appearance 
of syphilitic hour-glass in contrast to simple ulcer and 
cancer, 32; Results of combined mercury-lamp and 
deep, treatment of human lung tuberculosis, 61; 
Experimental grounds for treatment of lung tubercu- 
losis by, 61; Results in, treatment of menorrhagia, 
dysmenorrhoea, and uterine myoma, 71; Problems in, 
diagnosis of urinary calculi, 89; Removal of intra- 
cranial foreign body under, 232; Duodenal ulcer with 
special reference to its, diagnosis, 254; department 
of Scottish Women's Hospital, 293; treatment of 
uterine myomata, 402; Corroborative diagnosis of 
mastoiditis by means of, 515; localization of foreign 
bodies in eye by Sweet method, 611 
X-ray: See also Roentgen, Radium 



INDEX OF BIBLIOGRAPHY 



GENERAL SURGERY 

Surgical Technique 

Operative Surgery and Technique, icxj, 198, 316, 
432,518,615 

Aseptic and Antiseptic Surgery, 100, 198, 316, 432, 
518,615 

Anaesthetics, 100, 198, 316, 432, 518, 615 

General. Local. General subjects on anaes- 
thetics 

Surgical Instruments and Apparatus, 100, 198, 316, 
432,518,615 



Fractures and Dislocations, 105, 204, 321, 438, 523, 

620 
Surgery of the Bones, Joints, etc., 106, 204, 322, 438, 

524, 621 
Orthopedics in general, 106, 205, 322, 439, 524, 621 

Surgery of the Spinal Column and Cord 

Diseases and Deformities of the Spine, 107, 205, 323 , 
439- 525, 621 

Inflammations, timiors, fractures, surgery. 
Cord 



Surgery of the Head and Neck 

Head, loi, 198, 317, 433> Si9, 615 

Scalp. Skin. Nerves. Glands. Skull and Max- 
illa. Meninges. Brain, cerebnmi, cerebellum, 
hypophysis 

Neck, 102, 200, 318, 434, 519, 616 

Skin. Glands. Muscles and blood-vessels. 
Bones. Thyroid: Goiter, Basedow's disease. 
Graves' disease. Parathyroid. Retropharyn- 
geal conditions 

Surgery of the Chest 

Chest Wall and Breast, 102, 200, 318, 434, 520, 617 

Breast. Incisions, wounds, injuries, etc. Bones, 

Pleura. Mediastinum. Thymus 
Trachea and Lungs, 102, 201, 318, 434, 520, 617 

Trachea. Bronchi. Lungs 
Heart and Vascular System, 102, 201, 318, 434, 520, 

617 

Heart. Pericardivun. Aorta 
Pharynx and (Esophagus, 103, 319, 435, 520, 617 

Surgery of the Abdomen 

Abdominal Wall and Peritoneum, 103, 201, 319, 435, 
520, 618 

Incisions and drainage. Tumors. Retro- and 
pro-peritoneal conditions. Peritoneiun. Dia- 
phragm. Hernia. Omentum. Mesentery. Ura- 
chus. Diverticula 
G astro-Intestinal Tract, 103, 202, 319, 435, 521, 6i8 
Stomach and pylorus. Duodenum.- Small in- 
testines. Caecum. Appendix, Colon. Rectum 
Anus 

Secretions of, diagnosis, radiology, injuries, 
haemorrhages, vomiting, inflammations, ob- 
structions, hernia, ulcer, tumor, surgery, 
general therapy 
Liver, Pancreas, and Spleen, 104, 203, 320, 437, 522, 

619 
Miscellaneous, 105, 203, 321, 437, 523, 619 

Surgery of the Extremities 

Diseases of Bones, Joints, Muscles, Tendons. General 
Conditions Commonly Found in the Extremities, 
105, 203, 321, 437, 523, 620 



Surgery of the Nervous System 

Nervous System, 107, 206, 323, 440, 525, 622 
Inflammations, tumors, surgery 



Miscellaneous 

Clinical Entities — Tumors, Ulcers, Abscesses, etc., 
107, 206, 323, 440, 525, 622 
Tumors. Ulcers, Inflammations. Shock. 
Tissue transplantation. Siu-gical diseases 

Sera, Vaccines and Ferments, 108, 206, 324, 440, 526, 
622 

Serum. Vaccine. Ferments. Immunization 
Anaphylaxis 

Blood, 108, 207, 324, 440, 526, 623 

Blood picture in general. Haemorrhage. Coagu- 
lation. Thrombosis. Embolism. Transfusion 

Blood and Lymph Vessels, 207, 324, 441, 526, 623 

Aneurisms. Vessel suture and ligation. Lymph- 
vessels and glands 

Poisons, 108, 207, 324, 441, 526, 623 
Bacterial. Chemical. 

Surgical Therapeutics, 109, 207, 325, 441, 526, 623 

Surgical Anatomy, 109, 207, 325, 441, 527, 623 

Radiology, 109, 208, 325, 442, 527, 624 

X-ray. Electrical treatment and injuries. 
HeUotherapy 

Military Surgery, no, 208, 326, 442, 527, 624 

Surgical Pathology, no, 209, 327, 443, 527 

Industrial Surgery, 528, 625 

Hospital, Medicolegal, and Medical Education, in, 
209, 327, 443, 528, 625 



GYNECOLOGY 

Uterus, in, 210, 327, 444, 529, 625 

Txmiors. Haemorrhage. Inflammations. Mal- 
formations. Displacements. Injuries. Surgery 

Adnexal and Periuterine Conditions, in, 210, 328, 
444, 529, 626 

Ovaries. Tubes. Ligaments. Pelvic conditions 
in general 

External Genitalia, 112, 211, 328, 444, 529, 626 
Vagina. Vulva. Urethra. Clitoris 

Miscellaneous, 112, 211, 328, 444, 530, 626 



XXIX 



XXX 



INTERNATIONAL ABSTRACT OF SURGERY 



OBSTETRICS 

Pregnancy and Its Complications, 112, 211, 328, 444, 

530, 626 

Pregnancy. Eclampsia and toxaemias. Caesa- 

rean section. Abortion. Complications 
Labor and Its Complications, 113, 212, 329, 445, 531, 

627 

Contracted pelves. Abnormal presentations. 

Dystocia. Haemorrhage. Surgical treatment 
Puerperium and Its Complications, 113, 212, 329, 445, 

531, 627 

Diseases common to. Infections. Haemorrhages 
Miscellaneous, 113, 212, 329, 445, 531, 627 



Bladder, Urethra, Penis, 114, 213, 330, 446, 532, 628 
Trauma, calculi, displacement, malformation, 
haemorrhage, tumors, inflammations, surgery 

Genital Organs, 114, 213, 330, 447, 532, 628 

Testicle. Epididymis. Spermatic cord. Pros- 
tate 

Miscellaneous, 115, 214, 331, 447, 532, 628 

SURGERY OF THE EYE AND EAR 

Eye, 115, 214, 331, 447, 532, 629 

Glaucoma. Trachoma. Cataract. Inflammations 

Ear, 115, 215, 332, 447, 533, 629 

Outer ear. Middle ear. Internal ear. Mas- 
toids. Brain abscess of otitic origin, etc. 



GENITO-URINARY SURGERY 

Adrenal, Kidney, and Ureter, 114, 213, 330, 446, 531, 
628 

Adrenal gland. Kidneys. Ureters 

Trauma, calculi, displacement, malformation, 
haemorrhage, tumors, inflammations, surgery, 
functional tests of 



SURGERY OF THE NOSE, THROAT, AND MOUTH 

Nose, Throat, and Mouth (oral surgery) 116, 216, 332, 
448, 533, 629 
Nose: external, internal 
Throat: tonsils, adenoids, larynx, pharynx 
Mouth: palate, cleft palate, teeth, tongue 
General conditions 



INDEX OF AUTHORS 



Abadie, J., 244 
Abbott, A. W., 457 
Abelio, G., 74 
Abell, I., 510 
Abercrombie, R. G., 58 
Abernethy, E. A., 179 
Acuna, M., 602 
Adair, F. L., 304 
Adams, E., 430 
Adler, I., 488 
Aikins, W. H. B., 19 
Albee, F. H., 44 
Alberti, O., 388 
Allan, A. P., 51 
Allen, H. E., 147 
Amberg, E., 234 
Anderson, W. L., 479 
Andresen, A. F. R., 139, 

141, 549 
Andries, J. H.. 258 
Apert, E., 67 
Arana, G. D., 346 
Arboleda, A., 193 
Arcelin, 452 
Arganaraz, R., 312 
Armitage, G. L., Jr., 374 
Armitage, H. M., 374 
Armour, D., 270 
Arnaud, L., 539 
Arnold, J. O., 407 
Arrowsmith, H., 428 
Arteaga, I. F., 413 
Ascoli, 453 
Ashcraft, L. T., 607 
Ashhurst, A. P. C, 39 
Auer, J., 386, 489 
Austin, J. H., 560 
Auvray, 570 
Auwerda, J. C. M., 617 
Axtell, W. H., 463 

Bacmeister, A., 61 
Baetjer, F. H., 154 
Baitsell, G. A., 487 
Baldwin, C. H., 147 
Baldwin, J. F., 536 
Baldwin, M., 350 
Baldy, J. M., 184 
Balfour, D. C, 557, 588 
Bancroft, F. W., 588 
Bandler, S. W., 303 
Barbacci, O., 249 
Barclay, A. E., 228 
Barling, G., 58 
Barnert, C., 81 
Barnes, F. M., Jr., 302 
Barnes, F. R., 280 
Barnes, J. H., 194 
Barnes, R. H., 466 
Bamhill, J. F., 449 
Barr, R. A., 551 
Barron, M., 540 
Bartels, L., 19 



Bartlett, W., 347, 349 
Bates, H. J., 17, 509 
Bates, H. T., 243 
Bauman, G. I., 269 
Baumeister, L., 61 
Bayne-Jones, S., 32 
Bazy, 381 
Bazy, L., 610 
Bazy, M., 37 
Beach, R. M., 409 
Beach, W. M., 455 
Beatti, M., 378 
Beck, E. G., 288, 514, 545 
Beckman, E. H., 537 
Beer, E., 195 
Begouin, 357, 380 
Behan, R. J., 549 
Bell, A. J., 357 
Bell, E. T., 274 
Bell, F. M., 261 
Bell, R. G., 79 
Bello, A., 404 
Belot, 475 
Berard, L., 66 
Berens, T. P., 614 
Bergeron, J. Z., 20 
Beriel, L., 541 
Bernhard, A., 483 
Bernheim, B. M., 281 
Bernstein, E. P., 483 
Berry, H. M., 428 
Berry, J. M., 40 
Bichat, 453 
Binet, L., 361 
Binnie, J. F., 400 
Birtch, F. W., 399, 483 
Bissell, D., 510 
Black, C. E., 347 
Black, D., 234 
Blackburn, W. J., 97 
Blackwell, H. B., 612 
Block, E. B., 176 
Block, F. B., 301 
Boas, 364 
Boero, E. A., 504 
Boehme, G. F., Jr., 145 
Boggs, R. H., 389 
Boldt, H. J., 173 
Boiling, R. W., 41 
Bolognese, G., 487 
Bonnet, P., 570 
Boorstein, S. W., 569 
Boothby, W. M., 28 
Bourgeois, H., 425 
Boyd, G. M., 407 
Bradford, W. H., 253 
Brancati, R., 165 
Brandt, K., 575 
Braun, A., 619 
Brian, B., 154 
Bristol, L. D., 399 
Bromer, R. S., 156 
Brown, A.. 604 



Brown, C. P., 476 
Brown, E. D., 285 
Brown, T. H., 373 
Brown, W. L., 476 
Browning, C. H., 577 
Browning, W., 448 
Bruns, P. von, 168 
Bryan, C. W. G., 268 
Bryan, R. C., 35 
Bubb, C. H., 21 
Bucholz, C. H., 272 
Bulkley, L. D., 571 
Bull, C. G., 579 
Bullrich, R. A., 576 
Buquet, A., 177 
Burckhardt, H., 42 
Burge, E. L., 250 
Burge, W. E., 250 
Burk, 359 

Bumham, A. C., 535, 564 
Bums, J. E., 492 
Burnett, T. C., 385 
Burrows, E. C., 261 
Burrows, W. F., 261 
Butler, E. E., 578 
Byford, H. T., 50 
BytheU, W. J. S., 166 

Calkins, G. N., 273 
Callison, J. G., 96 
Cameron, D. F., 419 
Cameron, H. C, 472, 561 
Cameron, M. H. V., 185 
Campbell, W. C, 265 
Campbell, W. F., 473 
Camus, J., 291 
Canuyt, G., 195, 360 
Carderelli, A., 155 
Carman, R. D., 241, 366 
Carmody, T. E., 619 
Carr, A. M., 270 
Carr, W. P., 474 
Carrel, 65 

Carstens, J. H., 593 
Carter, W. S., 379 
Car\'allo, C, 296 
Case, J. T., 34, 62, 174, 370 
Cassimatis, 193 
Castex, M., 356 
Castex, M. R., 376 
Gates, B. B., 47 
Cathcart, C. W., 228 
CeUer, H. L., 486 
Chambers, J. S., 161 
Chamorro, T. A., 603 
Chaput, 44, 364 
Chatillon, F., 455 
Cherry, T. H., 56 
Chevassu, M., 138 
Chiaje, S. delle, 499 
Chislett, H., 255 
Churchman, J. W., 192 
Cifuentes, P., 512 



Clark, J. P., 613 
Clark, S. M. D., 498 
Clark, W. L., 491 
Claude, H., 47 
Clendening, L., 362, 454 
Clermont, 397 
Clevenger, W. F., 613 
Coakley, C. G., 516 
Coates, G. M., 426 
Coates, L. H., 368 
Coburn, R. C, 128 
Coffey, R. C, 77 
Cogswell, J. W., 178 
Cohn, I., 127, 265 
Cole, P. P., 21 
Collier, J., 271 
Collin, I., 367 
Collins, A. S. A. W., 71 
Collins, C. U., 37 
Commiskey, L. J. J., 415 
Condit, W. H., 70 
Connell, F. G., 552 
Cook, F. S., 21 
Cooke, J. v., 456 
Cope, V. Z., 235 
Coplin, W. M. L., 248 
Comer, E. M., 46 
Cosmettatos, G. F., 355 
Costa, N. P., 408 
Costa, R., 407 
Costa, S., 356 
Cotte, G., 539, 566 
Cotton, F. J., 372 
Crabtree, E. G., 84 
Crane, C.B., 611 
Crispin, E. L., 245 
Crosby, L. G., 491 
Cross, C., 376 
Crossen, H. S., 402 
Crowell, A. J., 514 
Cullen, T. S., 594 
Gumming, J. G., 161 
Cunningham, S. P., 472 
Gushing, H., 448 
Cutler, E. C, 400 
Cutler, F. J., 398 

Dabney, V., 97 
Dalton, F. J. A., 66 
Dambrin, C, 377 
Danforth, W. C, 409 
Danziger, F., 85 
Darling, B. C, 316 
Darnall, W. E., 593 
Darrach, W., 373 
DaSilva, R., 177 
Davidson, A. J., 40 
Davis, B. F., 129, 367 
Davis, C. H., 300 
Davis, D., 161 
Davis, E. G., 420 
Davis, E. P., 82 
Davis, G. G., 477 



XXXI 



xxxu 



INTERNATIONAL ABSTRACT OF SURGERY 



Davis, J. D. S., 470 
Dayton, A. B., 365 
Dean, H. R., 283 
Dean, L. W., 427 
Deaver, J. B., 35, 261, 467 
Decherd, H. B., 516 
Decref, 509 
Dehelly, 65, 493 
Dehogues, T. L., 94 
Delageniere, H., 476 
Delavan, D. B., 581 
DeLee, J. B., 185, 413, 509 
Delia Torre, P., 142 
Delia Valle, L., 277 
Delore, X., 539 
Delorme, E., 167 
Deluca, F. A., 499 
Del Valle, D., 423 
Dench, E. B., 94, 95 
Denechau, 548 
Denny, G. P., 161 
DePage, A., 370 
Dermer, 583 
Derr, J. S., 611 
Descomps, P., 388 
Desplas, B., 494 
DeTarnowsky, G., 159 
DeVUla, S., 416 
Dewey, K., 485 
Dewis, J. W., 32 
Diehl, H. E., 78 
Diena, G., 286 
Diesing, 397 
Dodge, G. E., 143 
Dolley, D. H., 578 
Don, A., 447 
Donald, A., 598 
Downes, W. A., 34 
Dreesman, 550 
Drueck, C. J.,465, 554, 555 
DuBose, F. G., 257 
Dubois, E. F., 485 
Duclos, 313 
Dumas, 65, 493 
Duncan, J. W., 183 
Dunham, K., 135 
Dunlop, J., 41 
Dupont, 567 
Dupuy, H., 431 
Durante, L., 98, 140, 358 
Duval, P., 131, 170, 548 
Dyas, F. G., 162 

Eccles, W. M., 56 
Edgar, J. C, 179, 184 
Edinger, L., 49 
Edwards, F. W., 260 
Eggleston, C., 578 
Eggstein, A. A., 238, 262 
Ehrenfest, H., 74 
Eikenbary, C. F., 263 
Einhorn, M., 38, 466 
Eisen, E. J., 315 
Elliott, G. R., 569 
Elliott, T. R., 251 
Elmer, W. G., 480 
Elsberg, C. A., 281, 569 
Ely, A. H., 597 
Emery, W. D., 230, 383 
Enderlen, 495 



Erkes, F., 421 
Ernst, N. P., 365, 582 
Ersner, M. S., 426 
Escalada, C., 431 
Estes, W. L., 564 
Evans, D. J., 78 
Evans, F. A., 160 
Evans, J. S., 26 
Eve, F., 350 
Everidge, J., 282 
Ewing, J., 60, 240 

Falco, A., 184 
Falls, F. H., 506, 601 
Farani, A., 176, 178 
Farrington, P. M., 430 
Faure-Beaulieu, 354 
Ferguson, L. M., 31 
Fernandez, J., 312 
Ferreyra, F., 411 
Field, J. A., 605 
Fiessinger, 493 
Fieux, G., 40 
Filhoulaud, 475 
Findley, P., 589, 596 
Finochietto, R., 248 
Fiolle, J., 495 
Fiolle, P., 495 
Fisher, H. R., 17 
Fitz, R., 385 
Fitzgibbon, G., 500 
Fleisher, M. S., 158 
Flesch, M., 167 
Flint, J. M., 293, 474 
Flumerfelt, G., 142 
Foley, S., 602 
Fonyo, J., 304 
Forselius, C., 574 
Forsell, G., 581 
Foulkrod, C., 179 
Fourmestraux, 566 
Fowler, H. A., 187, 608 
Fowler, R. H., 458 
Fox, H. H., 481 
Francis, L. M., 81 
Eraser, A., 416 
Eraser, J., 17, 243, 256, 551 
Frazier, C. H., 23, 462 
Freeland, J. R., 507 
Freeman, L., 58 
Frieberg, A. H., 45 
French, T. R., 429 
Freund, H., 89, 493 
Friedberg, S. A., 98 
Friedenwald, J., 34 
Friedlander, A., 607 
Friedman, J. C., 249 
Friedmann, M., 379 
Fuller, E. B., 280 
Fuller ton. A., 609 
Fullerton, W. D., 603 

Gaarde, F. W., 417 
Gallant, A. E., 72 
Gallie, W. E., 373 
Gallo, N., 378 
Gandino, N. T. F. de, 508 
Gasbarrini, A., 249 
Gates, F. L., 387, 489 
Gatewood, 240 
Gatewood, W. E., 96 



Gaucher, 67 
Gaudiani, V., 545 
Gauss, H., 576 
Gaut, S. G., 465 
Gaylord, H. R., 237 
Geist, G. A., 356 
Geist, S. H., 589 
Gellhaus, 52 
Gellhorn, G., 74 
Gentili, A., 306 
Georg, C., Jr., 136 
Gerber, I., 390 
Gewin, W. C., 188 
Gibbon, J. H., 422 , 
Gibson, F. S., 284 
Gibson, J. H., 422 
Giffin, H. Z., 557 
Gilbreth, F. B., 586 
Gillette, W. J., 572 
Gilpatrick, R. H., 417 
Gittings, J. C, 403 
Gley, 446 
Goadby, K., 381 
Goetsch, E., 131, 450 
Goldsborough, F. C., S96 
Good, R. H., 313 
Goodman, C., 483 
Goodwin, R. T., 69 
Gordon, G. S., 514 
Gordon, W., 585 
Gosset, A., 22, 49 
Goullioud, 452 
Grad, H., 410 
Graf, P., 381 
Granger, A., 511 
Grant, W. W., 228 
Graves, J. C., Jr., 480 
Graves, S., 454 
Graves, W. P., 590 
Gray, H. M. W., 20 
Green, N. W., 360 
Greenough, R. B., 63 
Greig, D. M., 472 
Grey, E. G., 24, 355 
Gronnerud, P., 238 
Grossi, v., 86 
Grossman, J., 564 
Groves, E. W. H., 373 
Groves, H., 565 
Guibe, 353 
Gundelfinger, 85 
Guthrie, D., 368 
Guttman, J., 453, 612 

Haberland, H. F. O., 57 
Hagedorn, O., 391 
Haines, W. D., 255 
Haller, 563 
HamUl, S. M., 403 
Hammes, 61 
Hammond, R., 155, 569 
Handheld- Jones, M., 71 
Handley, W. S., 248 
Hanes, G., 19 
Hanes, G. S., 464 
Hanford, C. W., 62 
Hannah, C. R., 82 
Hanzlik, P. J., 92 
Harada, T., 592 
Hardouin, P., 273, 374 



Harrar, J. A., 505 
Harris, J., 596 
Harrison, F. C., 475 
narrower, H. R., 573 
Hartmann, H., 354 
Haskins, H. D., 60 
Hassin, G. B., 270 
Hatch, E. S., 480 
Hatcher, R. A., 578 
Hawk, P. B., 502 
Hawley, D. C., 463 
Hawley, G. W., 264 
Hayes, G. B., 350 
Hays, H., 98, 515 
Hazen, H. H., 481 
Healy, W. P., 406 
Hedblom, C. A., 414 
Heineberg, A., 403, 503 
Heineck, A. P., 512 
Hektoen, L., 276 
Held, T. W., 453 
Henderson, F. F., 372 
Henderson, M. S., 154, 263, 

264, 477, 568 
Henderson, Y., 537 
Hendrix, B. M., 458 
Henes, E., Jr., 556 
Henessy, J. T., 195 
Henxici, A. T., 274 
Henry, H., 251 
Herbst, R. H., 192 
Hering, H. E., von, 349 
Hernaman- Johnson, F., 287 
Herrick, J. F., 29 
Hess, A. F., 53 
Heyerdahl, P. A., 580 
Higgins, H. L., 385 
Hill, I., 600 
HUl, T. C., 466 
Hingston, C. A. F., 183 
Hingston, D., 564 
Hirsch, I. S., 242, 491 
Hitzrot, J. M., 41 
Hoeve, H. J., 259 
Hoffman, P., 43 
Hofmann, E., 517 
Holbrooke, C., 183 
Holding, A. F., 133, 391 
Holland, 135 
Holmes, G. W., 167 
Holmes, J. B., 469 
Horrax, G., 284 
Horsley, J. S., 163, 517 
Horwitz, A. E., 145 
Hoskins, R. G., 159, 284 
Hoxie, G. H., 135 
Hubeny, M. J., 256 
Hudson-Makuen, G., 195 
Huertas, J., 138 
Huggins, R. R., 459 
Huguenin, M., 312 
Hull, A. J., 271, 392 
Hunner, G. L., 87 
Huntington, T. W., 146 
Hussey, A. A., 406, 598 
Huxley, F. M., 305 
Hymanson, A., 508 

Ireata, D., 307, 411 
Irving, F. C, 80^ 



INDEX OF AUTHORS 



XXXIU 



Isnardi, L., 292, 583 
Ivy, R. H., 315 
Iyer, H. N., 415 

Jablons, B., 144 
Jackson, C, 547 
Jackson, D. E., 18 
Jackson, H., 233 
Jacob, F. M., 24 
Jacobs, C. M., 568 
Jaugeas, F., 453 
Jefiferson, G., 35, 142 
Jennings, J. E., 358 
Jobling, J. W., 238, 262 
Jocqs, 312 
John, R. L., 570 
Johnson, C. C. 232 
Johnson, J. E., 256 
Johnstone, K. L., 270 
Jonas, A. F., 48 
Jones, E. O., 536 
Jones, F. S., 384 
Jones, R., 270, 375, 473, 

479, 568 
Judd, E. S., 57, 468 

Kahn, A., 161 
Kahn, M., 508 
Kakels, M. S., 85 
Kane, E. O., 43, 127 
Kanoky, J. P., 354 
Kantor, J. L., 262 
Kasahara, M., 604 
Kazanjian, V. H., 21 
Keefe, J. W., 535 
Kellogg, F. B., 98 
Kellogg, J. H., 296 
Kelly, H. A., 89, 166 
KeUy, M. F., 268 
Kendall, E. C, 134 
Kennedy, J. W., 169, 175 
Kenny, T. B., 557 
Kenyon, E. L., 430 
Keogh, A. H., 392 
Keschner, M., 449 
Keys-Wells, E. N., 492 
Kidner, F. C, 561 
Kilgore, A. R., 456 
Kleinberg, S., 270 
Kleiner, I. S., 277 
Klotz, O., 575 
Knapp, A., 611 
Knott, V. B., 551 
Koch, W. F., 26 
Kohlraann, W., 305 
Kradwell, W. T., 430 
Krause, H. A., 506 
Kretschmer, H. L., 417 
Krida, A., 278 
Krieg, A., 416 
Kroenig, B., 231 
Krouse, L. J., 464 
Kuegle, F. H., 286 
Kuemmell, 382 
Kuepferle, 61 
Kuettner, H., 57 
Kyle, D. B., 613 
Kyle, J. J., 516 

Lack, H. L., 316 
Lambert, R. A., 273 



Lanbrethsen, J., 452 
Lancer, T. F., 245 
Landa, G. M., 195 
Landivar, A. F., 541 
Landois, F., 42 
Landry, L. H., 22 
Landsman, A. A., 259 
Lane, A., 147 
Lange, S., 71 
Langrock, E. G., 56 
Lanier, L. H., 314 
Lansdown, R. G. P., 289 
Laroque, G. P., 296 
Latarjet, A., 398, 538 
Learmonth, M. E., 451 
Leavitt, M. A., 349 
LeBreton, P., 156 
Lee, J. R., 232 
Lefort, A., 190 
Leggs, A. T., 375 
Legueu, F., 191, 419 
Leigh, S., 462 
Lemon, C. H., 146 
Lenormant, C, 359 
Lent, E. J., 515 
Leonard, V. N., 365 
Leopold, J. S., 483 
Leopold, S., 354 
Leriche, 26 

L6riche, R., 361, 398, 540 
Leroy, 583 
Levy, 422 
Levy, I. H., 262 
LeWald, L. T., 360 
Lewin, P., 544 
Lewis, B., 19 
Lewis, D., 267, 388 
Lewisohn, R., 142 
L'Hermitte, J., 47 
Lieb, C. C, 552 
Lilienthal, H., 544, 546 
Linberger, 374 
Lind, J. E., 592 
Lindeman, E., 55, 597 
Lindsay, J. A., 551 
Little, E. G., 238 
Livierato, 355 
Llewellyn, T. H., 301 
Locher, R. W., 171 
Loeb, L., 158 
Long, J. W., 403 
Loop, R. G., 606 
Lord, J. P., 265 
Losee, J. R., 269 
Lott, H. S., 590 
Loughran, R. L., 612 
Loumeau,42i,423,424, 513 
Lounsbury, B. F., 372 
Lovett, R. W., 46 
Lubman, M., 194 
Luc, H., 545 
Ludlum, S. D. W., 481 
Lumiere, A., 66 
Lund, F. B., 556 
Lydston, G. F., 424 
Lyle, H. H. M., 476 

MacCarty, W. C, 358, 451 
Maccabruni, F., 541 
MacConkey, A. T., 282 



Macedo, C, 86, 186 
Macht, D. I., 165,311 
MacDonald, I., 252 
MacKay, W. A., 252 
MacKenzie, D. W., 90 
MacLennan, A., 229 
MacNider, W. D., 128 
MacWhinnie, A. M., 516 
Mahn, G., 231 
Makins, G. H., 246, 281 
Manges, M., 196 
Mangini, L., 193 
Mann, F. C, 33 
Mann, G., 265 
Mapes, C. C, 37 
Marchak, 567 
Marriott, W. M., 482 
Marsh, M. C., 237 
Marshall, H. W., 156, 472 
Martini, T., 366 
Marvel, E., 585 
Masserini, 453 
Massey, G. B., 158 
Mathews, F. S., 21 
Maurel, 348 
May, A. H., 596 
Mayer, E., 517 
Mayes, W. C, 517 
Maylard, A. E., 191 
Mayo, W. J., 36, 38, 553, 

5S8 
McArdle, J. S., 463 
McCann, F. J., 500 
McCarthy, J. F., 92 
McCarty, F. B., 129 
McConnell, A. A., 63 
McCouch, G. P., 481 
McCrae, T., 248 
McGlannan, A., 41 
McGlinn, J. A., 301, 598 
McGuire, S., 59 
McKenzie, B. E., 153 
McLean, A., 54 
McLean, E. H., 59 
McNeile, L. G., 600 
McNeile, O., 347 
McWhorter, J. E., 552 
McWilliams, C. A., 44 
Means, J. H., 573 
Meisenbach, R. O., 269 
Meltzer, S. J., 386, 387 
Mensing, E. H., 451 
Menzies, J. L., 239 
Merritt, A. H., 431 
Mertz, H. O., 311 
Metcalfe, J., 492 
Meyer, W., 53 
Middleton, W. S., 26 
Miller, G. I., 379 
Miller, R. B., 293 
Mills, R. W., 254 
Millwee, R. H., 288 
Minot, G. R., 161, 276, 

279 
Mitchell, A. G., 306 
Mitchell, W. C, 574 
Mitchell, W. T., Jr., 144 
Mocquot, P., 129, 363 
Moeller, O., 502 
Moiroud, 493 



Molina-de Saint Remy, A. 

H., 96 
Moncalvi, L., 162 
Monsaingeon, 49 
Montanari, E., 405 
Montgomery, E. E., 303 
Moore, A. B., 241 
Moore, I., 242 
Moore, J. E., 74, 473 
Moore, J. J., 601 
Moots, G. W., 574 
Morestin, H., 22, 350 
Morgan, E. A., 252 
Morgan, J. D., 448 
Moriarta, D. C., 490 
Morison, R., 584 
Morley, A. S., 260 
Mornard, P., 542 
Morris, R. T., 256, 573 
Morriss, W. H., 52 
Morton, C. A., 280 
Morton, D. J., 569 
Morton, H. H., 423 
Moschcowitz, E., 73, 459 
Mott, F. W., 63 
Mouat, T. B., 283 
Mouchet, A., 374 
Moulinier, R., 380 
MouUin, C. M., 51 
Moure, E. I., 515 
Moynihan, B., 65 
MuUally, G. T., 289 
Mundell, J. J., 81 
Myers, H. E., 619 

Nakano, H., 169 
Nathan, P. W., 474 
Nealon, W. A., 549 
Neill, W., 89 
Neuhof, H., 197 
Neuhof, S., 280 
Newbolt, G. P., 239 
Newcomet, W. S., 390 
Newell, C. H., 591 
Newman, D., 188, 308 
Nicholson, W. R., 411 
Nicolaysen, J., 575 
Nimier, 493 
Nix, J. T., Jr., 56s 
Norris, C. C., 409 

Ober, F. R., 375 
O'Brien, F.W., 262 
Olivella, R., 413 
Openshaw, T. H., 152 
O'Reilly, A., 46 
Orr, H. W., 478 
O'Shansky, A. L., 74 
Outland, J. H., 362, 454 

Packard, F. R., 94, 548 
Packard, R. G., 153 
Page, H. M., 446 
Painter, C. F., 55, 269, 376 
Pallasse, E., 452 
Palmer, C. L., $s 
Pardo, S. Y., 196 
Parker, D. B., 196 
Pascal, A., 500 
Pauchet, V., 365 



XXXIV 



INTERNATIONAL ABSTRACT OF SURGERY 



Payne, J. L., 130, 350 
Pavne, R. L., Jr., 510 
Peabody, F. W., 385 
Peacock, A. H., 189 
Peak, J. H., 471 
Peck, G. A., 450 
Peckham, F. E., 147, 155 
Pedersen, V. C, 418, 419 
Peet, M. M., 458, 462 
Pellegrini, E., 386, 387 
Pemberton, F. A., 590 
Pembrey, M. S., 446 
Pepper, O. H. P., 560 
Percy, J. F., 69 
Perkins, C. W., 287 
Perreau, H., 27 
Perret, M., 494 
Perrier, C, 424 
Perry, R. St. J., 232 
Perussia, F., 370 
Peterkin, G. S., 423 
Petersen, W., 238, 262 
Peterson, E. W., 279 
Peuret, A., 371 
Pfeiffer, D. B., 363 
Pfender, C. A., 174 
Pfister, F., 194 
Phelan, G. W., 183 
Phocas, 191 
Picque, R., 138, 371, 542, 

561 
Piery, 547 
Pighini, G., 490 
Pilcher, E. M., 392 
Plaggemeyer, H. W., 91 
Plass, E. D., 183 
Plummer, W. W., 132 
Polak, J. O., 179 
Policard, A., 494 
Pope, S., 32 
Porritt, N., 305 
Porter, M. F., 577 
Posados, I. N., 189 
Posey, W. C., 313 
Powell, C, 574 
Power, D., 457 
Pozzi, E., 189 
Pozzi, S., 371 
Preston, M. E., 147 
Priani, P., 449 
Prime, F., Jr., 62 
Primrose, A., 17 
Proust, R., 177, 493 

Quain, E. P., 512 
Quarella, B., 364 
Quenu, E., 131, 348, 362, 

375 
Quigley, D. T., 63 
Quillian, G. W., 275 
Quinby, W. C, 175, 188 
Quinlan, F. J., 314 
Quiros, D., 606 
Quiserne, 291 

Raab, F. H., 79 
Rabinovitz, M., 592 
Randall, A., 422 m 
Ransohoff, J., 70, 86 
Ransohoff, J. L., 70 



Rauch, R., 193 
Razetti, L., 67 
Raymondaud, H., 422 
Read, J. S., 426 
Reder, F., 601 
Reder, G. J., 133 
Regnault, I., 307 
Remy, C. E., 472 
Remsen, C. M., 23 
Reyn, A., 572 
Reynolds, G. E., 130 
Rhodes, G. B., 425 
Ribas, G., 599 
Rich, E. A., 475 
Richards, O., 551 
Richardson, M. L., 39 
Rico, I., 353 
Ridlon, J., 475 
Riggles, J. L., 592 
Riggs, T. F., 371 
Rist, 13s 
Ritter, 384 
Roberts, J. B., 41, 51 
Roberts, P. W., 265, 268 
Robertson, H. E., 282, 383 
Robertson, T. B., 286, 385 
Robinson, E. F., 372 
Robinson, J. E., 461 
Robinson, S., 240, 543 
Rochet, 421 

Rodenbaugh, F. H., 456 
Roffo, A., 378, 541 
Rogers, A., 128 
Rogers, M. H., 49, 478 
Rogoff, J. M., 284 
RoUet, E., 193 
Roost, F., 617 
Rosenow, E. C., 300 
Rosenzweig, S. B., 264 
Roubier, C., 452 
Rouhier, 363 
Rous, P., 52, 56, 384 
Rouvillois, H., 137 
Rowen, J. J., Jr., 160 
Rowlands, R. P., 283, 554 
Roy, D., 618 
Royce, C. E., 234, 542 
Royster, H. A., 158 
Rugh, J. T., 47 
Rumbaugh, M. C, 599 
Ryerson, E. W., 45, 479 

Saint, C. F. M., 292 
Salatich, P. B., 174 
Saliba, J., 248 
Salisbury, W., 305, 599 
Salvador, J., 301 
Sampson, H. H., 242 
Saphir, J. F., 259 
Savill, A., 293 
Saviozzi, V., 420 
Sayre, R. H., 271 
Schachner, A., 377 
Scheult, R., 596 
Schmidt, L. E., 84 
Schmidt, M., 46 
Schmidt, P., 353 
Schmitz, H., 580 
Schoepf, 61 
Schwartz, A., 129, 363 



Schwartz, A. B., 60 
Secord, E. R., 368, 565 
Seeley, W. F., 172 
Sejournet, 381 
Sekiguchi, S., 135 
Sellards, A. W., 276 
Sencert, L., 538 
Senger, W., 573 
Sequeira, J. H., 275 
Serafim, G., 473 
Sever, J. W., 155, 372, 603 
Sewall, H., 293, 574 
Shackleton, W. E., 272 
Shallenberger, W. F., 191 
Shannon, W. R., 308 
Sharpe, H. A., 601 
Sharpe, N., 571 
Sharpe, W., 157, 355 
Shaw, H. A., 346, 368, 462, 

556 
Shearer, T. L., 98 
Shipway, F. E., 446 
Shoemaker, G. E., 421 
Shorten, J. A., 347 
Sibley, W. K., 484 
Sicard, J. A., 377 
Siegel, P. W., 231 
Silvan, C., 361 
Silver, D., 145 
Silverberg, M., 92 
Silvestrini, L., 144, 360 
Simmonds, 378 
Simmonds, B. S., 264 
Simmonds, M., 86 
Simmons, C. C., 249 
Simon, A. R., 311 
Simon, C., 275 
Singleton, A. O., 279 
Siter, E. H., 422 
Skeel, A. J., 81 
Skillern, P. G., Jr., 263 
Skinner, E. H., 130 
Slemons, J. M., 602 
Slocum, M. A., 280 
Sluder, G., 97, 614 
Smead, L. F., 507 
Smith, A. J., 26 
Smith, E. O., 90, 310 
Smith, F. D., 561 
Smith, G. F. D., 602 
Smith, N. R., 276 
Smith, S. M., 94 
Smithies, F., 140 
Smyth, H. F., 163 
Smyth, J., 549 
Sonnenburg, C. N., 505 
Soper, H. W., 143 
Soresi, A. L., 139, 292 
Soubbotitch, V., 380 
Soule, R. E., 266 
Specht, A., 177 
Speed, K., 164 
Spiro, 355 
Squires, J. W., 33 
Staehhn, E., 186 
Staley, R. W., 91 
Stanley, L. L., 230 
Stanton, E. M., 503 
Stark, S., 502 
Stauffer, W. H., 503, 536 



Stein, A., 402 
Stenvers, H. W., 425 
Stevens, T. G., 405 
Stewart, G. N., 284 
Stewart, H. S., 127 
Stewart, L. F., 129 
Stewart, W. H., 391 
Stifel, R. E., 144 
Stincer, R., 197 
Stoddard, J. L., 400 
Stokes, J. H., 186 
Stoll, H. F., 371 
Stone, C. A., 566 
Stopford, J. S. B., 156 
Stout, A. P., 552 
Stout, P. S., 619 
Stutzin, 85, 397 
Sullivan, R. P., 550 
Swan, J. M., 134 
Sweet, J. E., 458 
Swett, P. P., 371 

Taddei, D., 189 
Tarnowsky, G. de, 266 
Taylor, G., 145 
Taylor, J. C, 501 
Taylor, R. F., 478 
Telfair, J. H., 411 
Tennant, C. E., 498 
Terrell, E. H., 466 
Terry, W. I., 456 
Thalhimer, W., 486 
Thomas, B. A., 421, 422 
Thomas, G. J., 84 
Thomas, T. T., 509 
Thompson, G. S., 231 
Thompson, W. M., 367 
Thomson, S., 427 
Throckmorton, T. B., 131 
Torrey, J. C., 162 
Tovey, D. W., 228 
Towles, C., 580 
Tracy, S. E., 597 
Truesdale, P. E., 501 
Truesdell, E. D., 604 
Troell, A., 165 
Tuffier, T., 148 
Tuley, H. E., 302, 454 
TuUidge, E. K., 282, 561 
Turner, D., 288 
Turner, G. G., 290, 420 
Turner, J. R., 52, 56 
Tweedy, E. H., 79 
Tyzzer, E. E., 274 

Udaondo, C, 362 
Ufifoltz, 494 
Uffreduzzi, O., 59 
Ugaz, R. I., 143 
UUman, J. S., 164 

Vail, D.T., 611 
Valdez, G., 461 
Valens, J. A., 508 
Van Leeuwen, G. A., 77 
Van Slyke, L., 78 
Vantrin, 410 
Veassy, C. A., 96, 427 
Vecchi, A., 284 
Verbrycke, J. R., Jr., 251 



INDEX OF AUTHORS 



XXXV 



Verhoeff, F. H., 94 
Vignes, 493 
Vignes, H., 302 
Villa, G. T., 378 
Villaret, M., 354 
Villavicencio, 484 
Villeon, P. de la, 30, 136, 

361 
Vilvandre, G., 232, 448, 

552 
Vincent, B., 63 
Vinograd-Villchur, 78 
Von Hacker, 232 
Von Wilier, P., 237 
Vulpius, O., 477 

Wachenheim, F. L., 143 
Waegeli, C, 505 
Wahl, H. R., 39 



Walker, J., 307 
Walker, J. W. T., 189 
Walker, M. H. Jr., 31 
Wallace, C, 30, 477 
Wallace, C. H., 499 
Walter, W., 18 
Walther, C, 374 
Walther, H. W. E., 311, 

607, 608 
Ware, M. W., 544 
Warner, F., 541 
Watkins, T. J., 173, 404 
Watson, C. G., 267 
Watson, L. F., 236 
Webster, J. C., 309 
Wechselmann, 87 
Weeks, A., 229 
Weil, R., 22 
Weinberg, M., 64, 289 



Weller, C. V., 185 
Wells, B. H., 247 
Whipple, G. H., 456 
Whitaker, R., 232 
White, E. W., 513 
Whitman, R., 567 
Wichmann, S. E., 80 
Wiener, J., 258 
Wight, J. S., 146 
Wilcox, H. W., 472 
Wilk, 417 

WiUard, D. P., 153, 478 
Williams, J. T., 178, 303 
WiUiamson, H., 504 
Willmoth, A. D., 277 
Wilmer, W. H., 515 
Wilson, C. F., 517 
Wilson, K. M., 304 
Wilson, W., 517 



Winslow, R., 25 
Wintz, H., 61 
Wolfe, R. D., 178 
Wood, F. C, 59, 62 
Woodall, C. W., 89 
Woolsey, G., 254 
Wright, A. E., 584 
Wyman, M. H., 87 



Yarros, R. S., 605 
Yeomans, F. C., 465 
Young, E. B., 301 
Young, J. K., 154, 263 



Zilva, S. S., 282 
Zobel, A. J., 93 



INTERNATIONAL 
ABSTRACT OF SURGERY 

JULY, 1916 



COLLECTIVE REVIEW 



THE VERMIFORM APPENDIX 

A 'Resume of the Literature 
By W. frank fowler, M.D., Rochester, New York 



THE literature pertaining to the appendix 
has been extremely illuminating and in 
many instances conclusive, during the 
past year. It is regrettable that a paper of this 
character cannot include all the excellent articles 
which were read in its preparation. The writer 
considers this compilation amply justified by the 
statistics of Murphy, herein quoted. 

ANATOMY 

Recent embryologic studies of folds, bands, 
and kinks have again demonstrated that various 
malpositions of the appendix are dependent upon 
partial or non-rotation of the gut. Schrup (i) 
reports a case of this character which presented 
the usual symptoms of appendicitis and cystic 
ovaries. At operation the cystic ovaries were 
found in the ovarian region, but there was no 
appendix, caecum, or ascending colon in the nor- 
mal position. The jejunum occupied the right 
half of the abdomen. The caecum was located 
behind the sigmoid. The appendix was long 
and congested. There were no adhesions. The 
mesocolon was apparently attached at the left 
side of the spinal column. The stomach, heart, 
and liver were in normal positions. A review 
of the literature convinces Schrup that complete 
transposition of the viscera is more common than 
the type which he reports. The pre-operative 
location of the heart on the right side would 
suggest the diagnosis in complete transposition. 
In childhood non-rotation of the colon accounts 
for unusual appendix positions. 



Corner (2) says: "Clinically, it is frequent to 
find in children that the caecum and appendix 
have not reached the iliac fossa, but have been 
delayed in their descent or become situated in 
the umbilical region. It is unusual for the left 
side of the abdomen or the pelvis to be reached. 
Appendicitis in the young is commonly atypical, 
and it is necessary to rely on the generality that 
acute abdominal disease in children is probably 
appendicitis." Other causes of malposition of 
the appendix in the adult are an abnormally long 
mesocolon and an unusually long appendix which 
may reach to the left side. 

Palamountain (3) reports a case of another 
type. His patient was a married woman, aged 1 8, 
a nullipara, who had had irregular menstruation 
for the past year. She was awakened by a sud- 
den severe, colicky pain in the midabdomen, 
which continued all night and was accompanied 
by vomiting. The pain was localized in the left 
iliac region and continued all the next day, with 
occasional vomiting. Castor oil and hot applica- 
tions did not relieve the pain. The next day she 
was driven to town. Examination revealed a 
medium-sized woman in severe pain. She leaned 
to the left side and kept the left thigh flexed. 
Menstruation had been delayed two days. Her 
temperature was 99.5°, pulse 120. The abdomen 
was tympanitic and extremely tender over the 
left side; percussion was almost unbearable; 
muscle spasm was pronounced. There was con- 
stant pain over the left lower abdomen. The 
uterus was slightly enlarged and softened. The 



INTERNATIONAL ABSTRACT OF SURGERY 



cervix was soft. There was some pain in the left 
adnexal region, and there was a suspicion of a 
mass in the left side. A tentative diagnosis of 
tubal pregnancy was made. Operation was 
refused until the next day when pain and fever 
had increased. Operation was performed fifty- 
eight hours after the onset. It was found that 
the sigmoid was on the right side; the ascending 
colon and ilium and a gangrenous appendix were 
on the left side. Peritonitis was present. Later 
examination located the liver on the left side 
and the heart on the right, a complete visceral 
transposition. No pregnancy existed. Death 
occurred in fifteen days from peritonitis. 

Wade (4) describes some very unusual necropsy 
findings. The subject, a colored infant 6 months 
old, died of pneumonia. The appendix, 12.5 
cm. long, was found to be congenitally implanted 
in the inguinal canal. There was no evidence of 
appendicitis, nor of hernia. It was evident that 
the testicle, in its descent, had carried the appen- 
dix with it. The tip of the latter was close above 
the testicle. The caecum was normally located. 

PHYSIOLOGY 

A meager knowledge of appendiceal physiology 
has been augmented by Heile (5), who states that 
his studies of the function of the appendix show 
that the musculature of the appendicular region 
and of the appendix itself act together to insure 
effectual peristalsis. The walls of the appendix 
secrete tryptic and amylolytic ferments. There 
is also an internal secretion of hormones which 
stimulates peristalsis when injected into rabbits. 

The investigations of Waller and Cole (6), 
which included the fluoroscopic examination of 
27 children, convince them that the appendix 
is a specialized part of the caecum, with a definite 
peristaltic and sphincteric action; that faecal 
material, normally retained in the appendix from 
one period of digestion to another, provides 
bacteria for colonic digestion; in brief, that the 
appendix is a physiological "culture tube." 
Incidentally the frequent occurrence of appendic- 
ular involvement revealed by examination of 
healthy children was surprising. Waller and 
Cole believe that appendicitis is essentially a 
lesion of early life. 

Gunn and Whitelocke (7) learned from experi- 
ments that the removed appendix ceases con- 
tracting when placed in ordinary Locke's solu- 
tion, but when placed in oxygenated Locke's 
solution at body temperature, the contractions 
recur. In appendices removed at operation 
"there are typically present larger contractions 
with (usually) superimposed smaller contrac- 



tions." A removed rabbit's appendix showed 
similar contractions, very much like those of the 
appendix in situ. They conclude that the con- 
tractions of the removed human appendix 
approximate those of the human appendix in situ. 
The nerve supply of the appendix is splanchnic 
and pelvic visceral. Appendices removed from 
children under ten years of age possessed the 
greatest contractions. "A severely inflamed 
appendix may still show spontaneous movements 
of not definitely aberrant type." 

ETIOLOGY OF APPENDICITIS 

The most noteworthy contribution to the 
etiological investigation of appendicitis is the 
conclusion of Rosenow (8) that this disease, in 
the absence of foreign body, is usually caused by 
streptococci; that these bacteria are located in 
some distant focus of infection; that they simul- 
taneously acquire an elective affinity for the 
appendix and entrance into the blood stream and 
are then carried to the appendix. The location 
and removal of foci of infection is an important 
measure of appendicitis prophylaxis. The co- 
existence of appendicitis and throat affections is 
thus explained. The danger in appendicitis lies 
in the fact that the anatomy of the appendix 
favors strangulation and the growth of facultative 
and strict anaerobes. In a more recent paper (9) 
on the elective localization of streptococci, Rose- 
now states that 14 strains from appendicitis 
produced lesions in the appendix in 68 per cent 
of the 68 rabbits injected, which is a marked 
contrast to an average of 5 per cent of lesions in 
the appendix in the animals injected with strains 
isolated from sources other than appendicitis. 
The localizations of the strains from appendici- 
tis, ulcer of the stomach, and cholecystitis as 
isolated, after animal passage, resemble one 
another very closely in cultural and other respects. 
Those from appendicitis are the least virulent, 
those from ulcer occupy a middle position, and 
those from cholecystitis are the most virulent. 
The virulence seems to be one of the factors that 
determines their place of survival after intra- 
venous injection. 

Anderson (10) notes the relationship between 
appendicitis and tonsillitis. He states that the 
tonsil is well recognized as a port of entry of 
many systemic infections, and reports three 
cases of acute tonsillitis, with apparent sub- 
sidence of throat trouble, soon followed by in- 
definite abdominal symptoms. In each instance 
a gangrenous appendix was found at operation. 
He summarizes as follows: (i) It is important to 
bear in mind the liability of appendicitis follow- 



FOWLER : THE VERMIFORM APPENDIX 



ing acute tonsillitis. (2) The appendicular in- 
volvement may be only part of a generalized 
infection, hence the gravity of such cases is out 
of proportion to the local symptoms. (3) Such 
cases tend to become atypical in their clinical 
course, and after smouldering, suddenly develop 
fulminating symptoms. (4) Chronic tonsillar in- 
fections should be kept in view as the possible 
cause of similar infections of the appendix. 
(5) At least some degree of local tenderness and 
rigidity is almost always to be elicited on careful 
examination of the abdomen in the right iliac 
region in appendicitis, though in rare cases these 
signs may be absent. 

The investigations of Savini (11) have con- 
vinced him that minute traumatic lesions of the 
appendix mucosa are very frequent. They are 
due to the presence of particles of carbon and 
iron. If these microscopic ulcers become in- 
fected necrotic appendicitis results. If they 
remain aseptic the condition found at operation 
depends upon the stage of connective-tissue 
repair. All stages of repair may be represented 
in dififerent portions of the same appendix. He 
considers obliteration of the lumen to be in- 
variably pathological. 

Hughes (12) believes that the initial cause of 
appendicitis is mechanical, a rotation of the 
appendix about its mesentery, and the degree 
of rotation determining the severity of the attack. 
This movement is made possible by: (i) a 
movable, loaded caecum; (2) a loss of tone in the 
abdominal muscles. He aflfirms that a proper 
amount of exercise would decrease appendicitis. 

Battle (13) reports two cases in which the 
mucous membrane of removed appendices was 
deeply pigmented a brownish black. The dis- 
coloration was confined to the mucous membrane 
and evidently extended into the caecum. He 
had previously reported four similar cases. The 
patients were all women, all of whom had suffered 
from chronic constipation, and had had attacks 
of appendicitis. The deposit proved, on analysis, 
to be iron. Only one patient had taken iron. 
Battle believes that the rollers which grind 
the wheat for flour are the source. He found 
unusual traces of iron in flour, but it could not be 
separated from the flour by a magnet. He con- 
cludes that iron particles may be an etiological 
factor in appendicitis. The sharp bits cause 
traumatic ulceration of the mucous membrane. 

Suzuki (15) made microscopical examination 
of 108 appendices removed at operation. He 
concludes that: (i) The oxyures may be found 
in the lumen, mucosa, or submucosa of the 
appendix without producing symptoms or anat- 



omical changes. (2) The presence of oxyures in 
appendicitis is usually accidental. (3) A true 
inflammation is provoked when many parasites 
penetrate the wall of the appendix and the 
abraded tissue becomes infected from the lumen. 
It is extremely rare. (4) The oxyures may cause 
a non-inflammatory, painful morbid condition 
in the appendix accompanied by traumatic 
destruction of the tissue and haemorrhage, a 
pseudo-appendicitis. (5) Some defects of the 
appendix wall are artefacts, but occasionally a 
cleft is formed by the parasite. 

Sherrick (16) reports three cases of traumatic 
appendicitis. Case i. A young man, plowing, 
received a hard blow in the right side of the ab- 
domen by the plow handle. Severe pain fol- 
lowed. He ran a typical course of appendicitis 
and died on the fifth day, having refused opera- 
tion. The autopsy showed peritonitis, and a 
perforated appendix with a concretion in the 
perforation. There was no history of previous 
attacks, but necropsy revealed evidence of previ- 
ous pathology. Case 2. A traveling salesman, 
by the derailment of a car, was thrown against 
the back of the seat in front of him. The severe 
initial pain soon disappeared, but returned a few 
hours later with typical symptoms of appendi- 
citis. Operation revealed a perforated, gangre- 
nous appendix. There was a history of two pre- 
ceding attacks. Case 3. A boy, aged six years, 
was struck in the abdomen by his brother's 
elbow. He immediately complained of severe 
abdominal pain, which continued with vomiting 
and the ordinary symptoms. A physician was 
called on the third day. Immediate operation 
revealed peritonitis, a perforated appendix with 
gangrenous mucous membrane, and a calculus. 
Sherrick quotes the conclusions of Deaver as 
follows: "(i) From personal experience and a 
study of the literature, trauma is never the direct 
exciting cause in a normal appendix. (2) Acute 
appendicitis can follow a severe blow upon the 
abdomen, or severe muscular strain, but the 
appendix will present evidence of pre-existing 
pathology. (3) Acute traumatic appendicitis 
is most frequent in males, due to their more active 
life, occurring between the ages of 10 and 25. 

(4) In an appendix previously diseased the 
liability to an acute attack following injury 
depends upon the degree of injury and the 
pathology in the appendix at the time of injury. 

(5) The mortality is high, due to late diagnosis, 
rapid gangrene, and perforation, and late opera- 
tion. (6) When the history suggests traumatic 
origin, a record should be made of the cause of the 
injury and also of the operative findings." 



INTERNATIONAL ABSTRACT OF SURGERY 



PATHOLOGY 

Stickney (17) reports the case of a woman, 
aged 39, who had had symptoms of chronic 
appendicitis for a year. At operation a small 
clubbed appendix was removed. The clubbed tip 
was a circumscribed solid tumor without lumen; 
examination revealed 5 small myomata in this 
area. Out of 647 reported cases of tumor of the 
appendix, only 3 were myomata. 

Primary carcinoma of the appendix, although 
formerly considered an extremely rare pathology, 
is stated by Meyer (18) to occur in 0.5 per cent 
of removed appendices. Meyer reports three 
cases. The diagnosis was made microscopically. 
Pre-operative diagnosis is impossible, and diag- 
nosis at operation unusual. The condition is 
histologically malignant, but clinically benign; 
nevertheless cHnically malignant cases do occur. 
The tumor occupies the appendix tip with obliter- 
ation of the lumen. The growth was noted to 
be of a yellowish brown color in one case. Ras- 
sieur (19) reports two cases. In the first the 
yellow color was noted on section and the diag- 
nosis made microscopically. The same color, 
observed on section in the second case, led to 
macroscopical diagnosis, which was later con- 
firmed by the microscope. 

Pseudomucinous cyst is a truly rare lesion. 
Phemister (20) states that it results from the slow 
accumulation of an altered secretion of the 
appendix produced by a mild inflammatory 
process. Most of the cases have occurred 
between the ages of 35 and 50. The fluid which 
accumulates during an acute attack of appendi- 
citis varies from serous to purulent or icherous. 
The accumulation either disappears rapidly with 
the subsidence of the acute inflammation, or 
escapes into the peritoneal cavity through a 
perforation. Persistence of this fluid with chronic 
cyst formation is rare. However, cases are re- 
ported of stenosis of the proximal portion, with 
pus accumulation in the part beyond, leading to 
the formation of chronic empyema of the appen- 
dix. Chronic hydrops following milder attacks 
in which the appendix is filled with a simple 
serous exudate is also very rare, because the 
mucous membrane is preserved in such cases, 
and its secretion changes the character of the 
contents so that pseudomucinous cysts usually 
result. The cause of the stenosis and retention 
of secretion is uncertain. It is probable that 
inflammation and involution are associated in 
varying degrees in the causation. Often there 
is no history of preceding attacks of appendicitis, 
and if so they have been mild. The lumen of the 



appendix is filled with a transparent, gelatinous 
material, which is usually quite thick. It con- 
tains no fseces and usually no bacteria. There 
are few clinical symptoms and development is 
slow and painless. Sometimes the first symptom 
is the appearance of a mass in the right, lower 
quadrant of the abdomen. Phemister reports a 
case in which the removed appendix was 21 cm. 
in length, and 21 cm. in its greatest circumference. 
It was filled with a thick, gelatinous material. 
Portions of the wall were thickened and some of 
these areas suggested calcified plaques. 

Phemister states that pseudomyxoma peritonei 
results from rupture of the cyst. Frankel in 
1 90 1 described the first case arising from a 
perforated colloid cyst of the appendix. About 
20 cases have been reported since. Perforation 
is usually symptomless and the pseudomucinous 
material is disseminated on the peritoneal surface 
in various sized masses. There are usually no 
symptoms subsequent to rupture as the contents 
are sterile. This condition is cured by removal 
of the cystic appendix, as the source of the mate- 
rial is removed and the remaining portion is 
absorbed. In a case reported by Ogilvie (21) 
the patient complained of something solid " tap- 
ping him on the inside" at the appendiceal 
region while he followed his daily work. A hard 
irregular mass was palpable over McBurney's 
point. A roentgenogram revealed a shadow 
which might be a calcified cyst of the appendix 
or a ureteral calculus. At operation a calcified 
appendix was removed. Examination revealed 
a pseudomyxomatous cyst whose walls were 
almost entirely calcified. The base of the 
appendix contained mucoid material, while the 
distal portion was filled with pus. 

Pfeiffer (22), in a paper on appendicular 
obHteration, states that chronic appendicitis 
pathologically includes low grade inflammation 
and end-results of such an inflammation. The 
latter is evidenced by cicatrices, strictures, kinks, 
and by destruction and replacement of mucosa 
by fibrous tissue, with obliteration of the lumen. 
The latter is not a physiological process. In 100 
surgically removed appendices the occurrence 
of obliteration was most frequent during the age 
of active inflammation (20 to 30 years), and was 
not dependent upon the advanced age of the 
patient. This contention is borne out by a case 
recently operated upon by the writer. The pa- 
tient was 70 years of age, and the appendiceal 
mucosa was gangrenous with obliteration of the 
lumen only at the tip. Pfeiffer classifies three 
types of symptoms due to an obliterated appen- 
dix: (i) reflex, due to irritation of the nervous 



FOWLER: THE VERMIFORM APPENDIX 



mechanism of the appendix; (2) local, due to 
mesenteric and peritoneal contractions and in- 
flammatory bands and adhesions affecting the 
appendix or contiguous bowel; (3) consecutive 
symptoms, general and local, consequent upon 
disturbed function of the illeocaecal region. 
Simple appendectomy avails for reflex symptoms, 
but in local and consecutive symptoms only in so 
far as the operation permanently relieves the 
symptom producing contractions, sclerosis, or 
adhesions. The determination of these latter 
conditions and the appropriate treatment, there- 
fore, awaits further observations and experience. 

Another type of obliteration is described by 
Bonn (23), who reports seven cases of filiform 
appendices. A filiform appendix, so named and 
described by Eastman (24), is a slender, white 
cord usually covered, entirely or in part, by a 
pericolonic membrane. If only partially covered 
the unconstricted portion may be of normal size. 
The end may be free or attached to the parietal 
peritoneum. The constricted part is without 
lumen. A filiform appendix may be mistaken for 
an adhesion, or the appendix may be considered 
congenitally absent or pathologically destroyed. 
Bonn believes that two processes are associated 
in the production of the filiform appendix; name- 
ly, a chronic inflammation and an involution due 
to constriction by the accompanying pericolonic 
membrane. 

Judd (25) reports a case of ''auto-amputation" 
of the appendix, a term used by Murphy (26). 
Judd's case was a young man with indefinite 
symptoms of appendicitis. During a kidney 
operation the appendix was brought into the 
incision. It was connected with the caecum only 
by a fine adhesion. Pinching at this point with 
the fingers entirely separated the appendix from 
the caecum. There was no opening into the 
caecum. The proximal end was also closed. The 
appendix was 7 cm. long, not dilated, and con- 
tained a small amount of mucoid material. It 
showed the lesions of a chronic interstitial in- 
flammation. 

DIAGNOSIS 

The diagnostic value of rigidity of the right 
rectus has been so greatly emphasized, according 
to Randall (27), that many cases of appendicitis 
have been neglected in the absence of this sign. 
He states that ordinarily rigidity of the right 
rectus is a reliable guide, but in some cases 
rigidity of the right external oblique is present 
in its stead. These cases are mild, many patients 
are about and attending to business, and a high 
polynuclear count is the only indication of a 



serious condition. In over 20 cases seen the 
past year by Randall, with rigidity of the right 
external oblique, and not of the right rectus, the 
appendix was retrocaecal or retrocolic. 

Ten Horn (28) reports that traction upon the 
right spermatic cord produces pain in appendici- 
tis. This he noted in 12 out of 15 cases. The 
cord is grasped above the testis and gently pulled 
without making pressure on the testis. He 
believes the pain to be due to irritation of the 
peritoneum about the internal ring. He doubts 
the value of the cremasteric reflex sign. 

Ruthkevitch (29) believes that chronic appen- 
dicitis is frequently diagnosed as some functional 
gastric or intestinal disorder of nervous origin. 
Many patients give no history of previous attacks 
or of characteristic pain. Constipation, tender- 
ness at McBurney's point, and temperature are 
often negative. Ruthkevitch could not elicit 
Rovsing's sign and leucocytosis was present only 
once. He concludes that there are no diagnostic 
signs of chronic appendicitis. Palpation is the 
best guide. He palpated the appendix in 60 per 
cent of cases and pain was produced in 88 per 
cent. The palpation also caused pain in the 
upper abdomen at the same time in many cases. 
His method of palpation is as follows: The flexed 
fingers of the right hand are pressed down between 
the external wall of the caecum and the abdominal 
wall. The fingers are then extended and an 
endeavor made to deflect the caecum toward the 
median line. This manipulation invariably pro- 
duces pain in chronic appendicitis. 

Bischoff (30) distends the previously emptied 
bowel with air through a rectal tube. By this 
means pain over McBurney's point is elicited if 
the appendix is diseased (Bastedo's sign). Pain 
over the appendix as ordinarily observed should 
not be considered diagnostic of appendicitis as it 
is caused by other conditions. 

Lanz (31) states that frequent and painful 
urination in children may be an early sign of 
appendicitis. When the finger is introduced 
into the right inguinal canal the muscles contract 
about it if the appendix is inflamed. The cord 
is painful and tender. Contrary to Ten Horn, 
Lanz believes that the cremasteric reflex is weak 
or absent in acute appendicitis. 

Sutton (32) reports a case of appendicitis with 
unusual features in a young, unmarried woman. 
At 5 a.m. he found the patient suffering from 
intermittent, colicky, abdominal pain; abdomen 
tympanitic; temperature and pulse normal. No 
abdominal tenderness. He gave soap-suds ene- 
ma, liquid diet, and castor oil. Diagnosis: acute 
intestinal indigestion. At 4 p.m. the tempera- 



INTERNATIONAL ABSTRACT OF SURGERY 



ture was ioo°, pulse 90; pain as before; slight 
localization of pain over McBurney's point. 
Abdomen slightly tympanitic. Return of enema 
good, constipated mass. Treatment: ice-bag to 
right iliac fossa, liquid diet. Diagnosis: acute 
appendicitis. Called at 5 a.m. next day; the 
patient was suffering from sharp, shooting pains 
in the vulva, in addition to abdominal pain of the 
same character as before. Four ounces of clear, 
straw-colored urine were obtained by catheteriza- 
tion. Temperature 102°, pulse no; marked 
tenderness over McBurney's point; slight rigidity 
of right rectus. On consultation immediate 
operation was advised. At operation the distal 
end of the appendix was found in a ruptured 
abscess, firmly adherent to the posterior wall of 
the bladder, and a beginning peritonitis. Sut- 
ton believes the symptom of sharp, shooting pain 
in the vulva indicates an adhesion of the posterior 
wall of the bladder. This symptom is explained 
by the fact that the vulva and bladder are sup- 
plied in part by the sacral plexus. The diagnosis 
was complicated in this case by ovarian pain and 
by inadvisability of bimanual examination, as the 
patient was a virgin. 

Randolph (33) reports the case of a man who 
had an acute illness a few months before consult- 
ing him. This illness confined the patient to 
bed and was accompanied by fever. The diag- 
nosis was sciatic rheumatism. Since then his 
health had been poor. He had lost weight, had 
dyspepsia and palpitation and was unable to 
work. He was apprehensive and thought he 
might have heart-disease or cancer. A clear 
cut diagnosis was impossible. Under hygienic 
treatment he improved. Three years later he 
had an acute abdominal attack, which was 
diagnosed as appendicitis. At operation the 
appendix was found to be very long and its distal 
end was situated against the spinal column, close 
to the upper division of the lumbosacral cord. 
There was a small abscess at the appendix. 
Randolph concludes that the initial attack of 
"sciatic rheumatism" was acute appendicitis, 
with peripheral pain in the sciatic nerve due to 
the proximity of the inflammatory focus to its 
fibers of origin. This case illustrates that so- 
called sciatica is a symptom, not a disease, and 
most often the etiologic factor is to be found above 
the level of the sacrosciatic notch. 

The roentgenoscopic evidence in appendicitis 
is discussed by Eisen (34). He states that the 
first reports of X-ray demonstration of the appen- 
dix were made by English and French roent- 
genologists in 1 913, but Americans realized the 
value of X-ray examination in 191 2. Eisen con- 



siders X-ray findings a valuable aid to diagnosis. 
A normal appendix lumen does not rule out in- 
flammation. He reports 36 cases, from 16 to 
60 years of age. In 6 there was a stricture near 
the tip with inflammation distal to the stricture. 
He calls these cases "drum stick appendicitis." 
No classical symptoms were present, nor clinical 
diagnosis made, in the majority of his series. 
Diagnosis was doubtful in most; in some the 
clinical diagnosis of gastric ulcer was made, 
while in others suspicions of duodenal or gall- 
bladder involvement existed. In 30 out of 36 
cases he made roentgen diagnoses of appendicitis, 
which were confirmed at operation. The X-ray 
reveals the cause of vague stomach symptoms in 
appendicitis to be due to pylorospasm. Eisen 
considers the most valuable roentgen symptom 
to be pain on direct pressure over the appendix, 
or when making traction upon or displacing it. 

Imboden (35) states that the probable reason 
the normal appendix is not always visualized is 
that it fills and empties between observations. 
Failure in filKng may also be due to: (i) oblitera- 
tion of its lumen; (2) adhesions or kinks near the 
proximal end; (3) an acute attack with infiltra- 
tion of the mucosa; (4) the lumen may be ob- 
structed by a fecolith or filled with contents not 
bearing an opaque material; (5) it may be retro- 
csecal, in which event if the caecum is partially 
empty the stereoroentgenogram usually reveals 
it. He concludes that: (i) Retention of appen- 
diceal contents after the caecum is empty should 
be regarded as suggestive of chronic appendicitis. 
(2) A tender area located in the course of the 
appendix must be regarded as suspicious. (3) 
The Trendelenburg position affords an unexcelled 
opportunity to study this area. (4) Stereoroent- 
genography affords the increased amount of 
information usual to this method in general. 

In response to the following questions: (i) 
What is the significance of barium retention in 
the appendix? (2) What is the significance of 
inability to demonstrate the appendix by means 
of the roentgen ray? (3) What are the roentgen 
signs of appendicitis? Personal communications 
were received, as follows: 

Dr. James T. Case: "Barium in the appendix 
is an abnormal phenomenon. It by no means 
indicates surgery. If, by accurate palpation of 
the barium-filled appendix, we are able to deter- 
mine adhesions, kinking, irregularities of the 
lumen, poor drainage (two to three days or 
longer), then we have surgical indications. The 
poorer the drainage the greater the danger. In- 
ability to demonstrate the appendix by means 
of the roentgen ray depends upon: First, obstruc- 



FOWLER : THE VERMIFORM APPENDIX 



tion of the lumen by an obliterating appendicitis, 
by turgescence of the tissues attending a recent 
inflammation, or kinking or adhesions near the 
base of the appendix. Second, the appendix 
may fill, but lie so definitely retrocaecal, closely 
adherent to the caecum, that it cannot be seen. 
Also great local tenderness or rigidity of the 
abdominal muscles may prevent accurate manipu- 
lation. Nevertheless, when the appendix re- 
mains filled longer than the caecum, we can 
demonstrate it. Third, failure to use the fluoro- 
scope. Not once in 50 times is the appendix 
seen in the ordinary roentgenogram. Not even 
simple fluoroscopic observations will sufl5ce. 
One must manipulate with the hands or with the 
wooden spoon or both. In acute appendicitis 
manipulation is unwise, but a barium enema will 
often identify tenderness on pressure as being 
over the appendix. I have discovered several 
cases of left-sided appendicitis in this manner. 
As to the roentgen signs of appendicitis: A. In 
acute appendicitis no signs are needed, except 
the barium enema, as above noted. B. The 
roentgen signs of a chronic condition are: (i) poor 
drainage; (2) localized tenderness on accurate 
palpation done under fluorescent screen guidance ; 
(3) kinking; (4) irregularities in the lumen so that 
the appendix is bulbous at the tip, and especially 
poorly drained at the tip; (5) associated adhesions 
to the caecum and terminal ilium; (6) unduly long 
or unduly large appendix. All these signs need 
not be present. The diagnosis should not be 
based upon roentgen findings alone." (Dated 
December 9, 1915.) 

Dr. G. E. Pfahler: "Barium retained in the 
appendix after the bowel is entirely empty prob- 
ably indicates a relaxed or inflamed appendix. 
Inabihty to demonstrate the appendix by means 
of the roentgen rays may mean that the appendix 
is obliterated or that it is filled with some other 
material and will not permit the barium to enter 
it. The roentgen signs of appendicitis are local- 
ized tenderness over the appendix, fixation, 
angulation, constrictions, local dilatations, adhe- 
sons about the caecum, incompetent ileocaecal 
valve, and undue retention." (Dated December 

9, 1915-) 

McWilliams (36) suggests the difficulty of 
diagnosis in cases of chronic appendicitis in which 
local pain and tenderness are mild or absent. 
These cases are characterized by distant reflex 
disturbances. He classifies them as follows: 
(i) Pain type, characterized by cohcs in children, 
simulating gastric or duodenal ulcer, or gall- 
stones: This class includes cases of pylorospasm. 
(2) Nausea type. (3) Vomiting type. (4) Gas 



type. (5) Intestinal type characterized by 
toxaemia producing anaemia; chronic constipa- 
tion; chronic diarrhoea and colitis. (6) Bilious 
or toxic type with headache. (7) Neurasthenic 
type. Medical treatment is of no avail. He 
warns against the use of such terms as nervous 
indigestion, neurasthenia, gastralgia, intestinal 
toxaemia, and bilious headaches as indicating a 
functional disturbance unless an organic basis 
can be ruled out absolutely. 

Morley (3,7) calls attention to the frequent 
errors in the diagnosis of chronic appendicitis, 
particularly that type in which there has never 
been an acute attack, and which is characterized 
by chronic pain and some tenderness, usually 
accompanied by constipation. He considers 
Lane's kink to be a practically symptomless 
congenital band. Jackson's pericohc membrane, 
also of congenital origin, may sometimes produce 
symptoms simulating chronic appendicitis, but 
more often these symptoms are due to the "mo- 
bile proximal colon" associated with it. The 
latter condition may be present without the mem- 
brane and with or without appendicitis. Inflam- 
matory bands in this region are tough, fibrous, 
opaque, and not very vascular, while congenital 
adhesions are translucent, more yielding, filmy,, 
and vascular. Morley believes that chronic 
inflammation of the right adnexa is the com- 
monest cause of erroneous diagnosis. Often a 
precise pre-operative diagnosis is impossible. 
An adequate incision is imperative, preferably 
vertical through the right rectus. 

Longo (38), in a strikingly similar paper, 
groups these confusing conditions under the 
term "pseudo-appendicitis." He, however, main- 
tains that Lane's kink produces symptoms simu- 
lating chronic appendicitis. 

Kenefick (39) believes that spasm of involun- 
tary muscles may be caused by local irritation in 
chronic appendicitis. He cites three cases, one 
of false angina without subjective symptoms of 
appendicitis, the second, oesophageal spasm 
during deglutition with a negative history of 
appendicitis. Diagnosis of appendicitis was 
made by eliciting sharp pain on deep pressure 
over the appendix and by roentgenograms. 
Operation was refused in both instances. In the 
third case the patient was healthy until three 
years ago when she began to vomit immediately 
after eating. Two months later she had two 
attacks of acute appendicitis which subsided. 
She continued to vomit. Within a month an 
exploratory incision was made. The stomach 
was normal, the appendix was examined but not 
removed. Kenefick made the diagnosis of chronic 



INTERNATIONAL ABSTRACT OF SURGERY 



appendicitis by palpation and X-ray. This was 
confirmed by operation and the patient has re- 
gained her normal health. Kenefick says, "The 
irritation or traction spasm originates at some 
particular attachment of the appendix to a 
branch of the mesenteric plexus and reaches the 
musculature of the stomach by way of the mesen- 
teric and celiac plexus as follows: (i) hepatic 
plexus and plexus gastroduodenalis to the pyloruls; 
(2) plexus gastro-epploica dextra to the pylorus 
and lesser curvature; (3) plexus gastroduodenalis 
to the fundus and region of greater curvature. 
Afferent impulses in general pass from an in- 
flamed appendix to the mesenteric ganglia, su- 
prarenal ganglia, vagus to medulla and cortex 
independent of the spinal centers." 

Aaron (40) previously had noted that pressure 
over the appendix caused epigastric pain. Re- 
cently, while examining a case of chronic ap- 
pendicitis with the fluoroscope he induced a 
pylorospasm by pressure over the appendix, and 
coincident epigastric distress of which the 
patient had frequently complained. Aaron be- 
lieves this reflex pain is caused by pylorospasm, 
and ventures the opinion that the gastric 
symptoms of appendicitis are also due to this 
spasm. 

Aynesworth (41) states that the average in- 
cidence of appendicitis in children up to 15 years 
of age is 15 per cent. The large number of pus 
cases are due to late diagnosis and rapid develop- 
ment. Cases have been reported as early as the 
fifth week. Failure to make a diagnosis is due 
to oversight rather than to symptomatology. 
Unfortunately other acute, mild abdominal con- 
ditions are common, leading to late diagnosis, 
and children do not readily localize painful areas. 
The history is scanty. Nevertheless Aynes- 
worth believes that the diagnosis can be made 
fairly early. Abdominal pain is usually the 
first symptom. Children with even shght peri- 
toneal involvement protect the abdomen very 
carefully. The appendix may be anywhere in 
the abdomen. When it lies in the pelvis there 
may be no abdominal rigidity, and tenderness 
only deep in the pelvis. In the presence of 
bladder irritation or doubt of diagnosis a rectal 
examination should be made. Pain, vomiting, 
tenderness, rigidity in any part of the abdomen, 
and fever strongly indicate appendicitis. Gastro- 
enteric affections must be excluded. Examina- 
tion of the lungs should be made in children 
whenever an acute abdominal condition is pre- 
sented. 

Fleischner (42) reports the following case: 
A child 8 years of age became acutely ill with 



fever, vomiting, and pain in the right side of the 
abdomen. Twelve hours after the onset there 
was a leucocytosis of 30,000. A tentative 
diagnosis of appendicitis was made. Upon 
examination light percussion of the chest re- 
vealed relative dullness over the right lower lobe 
of the lung and on auscultation the breathing was 
slightly diminished. There was no distention of 
the abdomen and abdominal respiration was 
normal. Considerable pain was complained of 
over McBurney's point and extending upward, 
but neither tenderness nor rigidity was com- 
mensurate with the pain. Operation was post- 
poned for twelve hours. At this time pneumonia 
symptoms were more evident. In twenty-four 
hours there was no doubt of pneumonia and 
pain had disappeared. 

Gage (43) states that pain, tenderness, and 
muscular spasm in the right iliac region occur 
during typhoid and render differentiation from 
appendicitis difficult. The difficulties are in- 
creased by the fact that the appendix does share 
in the intestinal lesions of typhoid, as instanced 
by case reports of ruptured typhoid ulceration 
of the appendix. Gage divides the appendicitis 
of typhoid into 3 classes: (i) appendicitis, an 
accidental accompaniment of typhoid, or a 
chronic condition become active; (2) typhoid 
ulceration of the appendix; (3) appendicitis oc- 
curring so soon after typhoid as to be due prob- 
ably to it. An unusual case of post-typhoid 
appendicitis was reported by Stokes and Arnick 
(44). A young man who had had typhoid 13 
years before, developed acute appendicitis. The 
appendix was gangrenous and the bacillus of 
Eberth was cultured from it. The Widal reac- 
tion was positive. Was he a carrier? Several 
cases have been reported of accidental complica- 
tion of appendicitis without evidences of typhoid 
involvement, but due to mixed infection with- 
out typhoid bacillus. Gage reports a case in 
which acute right iliac pain, rigid rectus, and 
vomiting developed when the typhoid tempera- 
ture had been normal for five days. The leu- 
cocyte count rose rapidly to 1 8,000. Laparotomy 
for probable perforation revealed an unruptured 
gangrenous appendix lying in a walled off abscess. 
The pathologist reported typhoid ulceration and 
the presence of typhoid and colon bacilli, as well 
as streptococci. Gage believes that careful 
examination of removed appendices for so-called 
accidental inflammation would reveal the pres- 
ence of typhoid lesions in many cases. He 
emphasizes the importance of a rising leucocyte 
count. 

Winslow (45) reports 4 cases which were oper- 



FOWLER : THE VERMIFORM APPENDIX 



ated upon early for rather typical symptoms of 
appendicitis. In these the Widal reaction was 
negative. Operation revealed a lack of appendi- 
cular pathology but the presence of enlarged 
retroperitoneal glands, thus leading to a tentative 
diagnosis of typhoid. Subsequently the cases 
ran through typical typhoid phases. Typhoid 
should be recognized by a low leucocyte count 
(although it may be low in serious or fatal appen- 
dicitis) , by less muscular rigidity and tenderness, 
by more headache and the liability of typhoid 
occurring during the fall. Mistake in diagnosis 
may be avoided in taking the history by deter- 
mining whether fever or pain occurred first, 
whether pain was sudden and severe, or whether 
it followed headache, malaise, and fever. If 
rigidity is not pronounced, even though there 
be pain and tenderness in the right lower quad- 
rant, and if the leucocyte count is low, do not 
operate until the diagnosis is clear. 

Sappington (46) reports the case of a young 
lady, aged 21 years, who had complained of 
anorexia and malaise for three days and was then 
suddenly taken with general abdominal pains, 
without nausea or vomiting. Her temperature 
rose to 102.4° F-> pulse 120, respiration 20, white 
cell count 12,000. The next morning, December 
27th, her temperature was 103° F., pulse 118, 
with pain and tenderness localized in the right 
iliac fossa. She had received the last of three 
immunizing injections of typhoid vaccine the 
preceding month. A diagnosis of appendicitis 
was made. Operation revealed an appendix 
which did not account for the symptoms. Her 
temperature continued between 103° and 104° F., 
and pulse above no. December 28, leucocytes 
were 11,600; December 29, negative blood culture; 
December 30, Widal reaction, as anticipated 
from immunization, was positive; December 31, 
second blood culture was positive for typhoid 
bacillus; January 4, leucocytes were 5,400 and 
rose spots appeared. The patient ran an average 
typhoid course to recovery. 

Wolfsohn (47) reports several cases sent to the 
hospital with diagnoses of appendicitis. They 
were not acutely ill, but for a number of days 
had suffered malaise. They all had diarrhoea 
and pain in the abdomen, the diarrhoea being 
unaffected by medication. There was tenderness 
over the appendiceal region without rigidity of 
the abdominal wall. No typhoid bacilli were 
found in the stools, urine, or blood. Appendec- 
tomy was performed in 10 or 12 cases, followed 
by the immediate disappearance of symptoms 
and prompt recovery. The lesions in the appen- 
dix were mild, but in several cases cultures of 



typhoid and paratyphoid bacilli were grown from 
the inner walls of the appendix although absent 
elsewhere. These patients had previously re- 
ceived typhoid vaccine which apparently had 
rendered their tissues immune to the bacilli, with 
the exception of the appendix. 

In a review of 157 cases of kidney and ureteral 
stone Cabot (48) notes that of 26 patients who 
had been previously subjected to unnecessary 
operation for various non-existent abdominal 
conditions, 10 had had appendectomy and 7 had 
had exploratory laparotomy. He states that 
renal colic is absent in many cases and when 
present may be mistaken for the pain caused by 
other abdominal lesions. The urine frequently 
remains normal. The X-ray is often negative, 
but a case in which the pain symptoms, X-ray 
evidence, and urinary findings are all negative, 
is very unusual. 

Braasch and Moore (49) state that when the 
pain of stone is localized to the area of the lower 
ureter, particularly on the right side, it may so 
closely simulate appendicitis that, given a normal 
urine, "an exploration of the appendix might be 
justifiable without preliminary roentgenographic 
examination." 

Gage (50) states that in acute appendicitis the 
ileocolic glands may be moderately enlarged. 
They show merely inflammatory changes on 
section. He reports 11 cases, diagnosed and 
operated upon by him for appendicitis, in which 
the appendix was normal or approximately so, 
but he discovered several enlarged glands in the 
ileocolic mesentery. These were tuberculous. 
He excised the glands and removed the appendix. 
The prognosis of this local tuberculosis he be- 
lieves to be favorable following excision. 

Case reports of Meckel's diverticulitis by 
Watson (51) and Strode (52) again demonstrate 
the impossibility of making pre-operative differ- 
entiation between this condition and appen- 
dicitis. 

Riggs (53) reports four cases of effusion into 
the bowel wall in which the symptomatology 
closely resembled appendicitis. A doughy sensa- 
tion in several cases suggested abscess. The 
effusion occupies the last few inches of ilium and 
may extend to the caecum. The lesions consist 
of a reddish, sharply defined thickening of the 
bowel wall and mesentery. He regards these 
as due to toxaemia, with such outward evidences 
as urticaria, erythema, angioneurotic oedema, 
and purpura. 

Waller (54) reports the case of a girl 8 years of 
age who was seized with sudden, violent abdomi- 
nal cramps while at stool. She lost consciousness 



lO 



INTERNATIONAL ABSTRACT OF SURGERY 



but soon recovered. Nausea and vomiting were 
followed by relief. There was slight tenderness 
in the lower right quadrant. At operation, upon 
delivery of the appendix, the partially anaes- 
thetized patient strained causing the apparently 
normal appendix to inflate alarmingly. Pressure 
was required to accomplish deflation. The 
appendix contained a No. 6 bird shot. There 
were no inflammatory changes. Waller believes 
that this case accounts for hitherto puzzling 
attacks of acute colic in which the appendix was 
not pathological but contained small concretions 
or foreign . bodies, these concretions or bodies 
acting as a ball valve, preventing ready deflation 
and producing symptoms of colic. 

Strauss (55) reports five cases of extraperi- 
toneal appendicitis which he classifies under three 
heads: (i) Those presenting a straightforward 
picture of appendicitis. In these cases the ap- 
pendix cannot be found until the peritoneum is 
incised near the caecum and the latter lifted up. 
(2) Those simulating a perinephritic abscess. 
This type is characterized by pain, tenderness, 
and swelling in the right lumbar region. 
Through the lumbar drainage incision it may be 
possible to remove the appendix without enter- 
ing the peritoneum. (3) If the appendix is not 
removed a persistent faecal fistula may result. 
Foetid pus obtained from a lumbar abscess is 
probably due to disease of an extraperitoneal 
appendix. Careful search should be made before 
deciding that the appendix is absent or has 
sloughed away. 

Lichty (56), who reports about 700 cases of 
appendicitis from the view point of the internist, 
is impressed with the fact that many cases of 
supposedly chronic appendicitis are operated 
upon without relief of symptoms. He summar- 
izes as follows: (i) A close co-operation of physi- 
cian and surgeon is necessary to obtain the best 
results. (2) Since only 8 patients out of about 
700, under all conditions and circumstances, died, 
the disease need not be considered with such 
alarm. (Lichty refers to cases hurriedly diag- 
nosed and operated upon for chronic appendicitis 
in which there may be no pathology in the 
appendix.) (3) An early operation during the 
first acute attack is not only safest but will likely 
prevent a life of more or less chronic invalidism. 
(4) A careful routine study of the leucocytes in 
acute appendicitis is of diagnostic value. (5) A 
routine study of the gastric secretion in chronic 
appendicitis yields valuable information (hyper- 
chlorhydria). (6) The end-results in cases of 
chronic appendicitis are often unsatisfactory and 
cannot be definitely foretold. 



TREATMENT 

Guthrie (57) reports the use of the serum and 
vaccine of colon bacillus in 22 cases of appendi- 
citis. All recovered without operation. There 
was one recurrence; here, too little of the serum 
was used and no vaccine. The reUef from pain 
was striking. Serum should be used before pain 
becomes localized. He gives 20 ccm. of the 
serum and a few days later 100,000,000 colon 
bacillus vaccine to prevent recurrence. The 
"fixation of complement test" should be made 
and if some other organism is the determining 
cause a corresponding serum or vaccine is indi- 
cated. 

Syms (58) reports a mortality of 100 per cent 
in a series of peritonitis cases of appendiceal 
origin in 1904. The mortality of a series in 
191 2 was 16 per cent. Improved operative 
methods have decreased the death-rate. Syms 
agrees with Murphy that perforative peritonitis 
tends to be localized or general from the very 
start, depending upon the kind of bacterium 
responsible and the patient's resistive power. 
He disagrees with Stanton (59) in his conclusion 
that dissemination of peritoneal infection is 
largely a matter of peristalsis and that the quiet 
afforded by withholding food and water by mouth 
will prevent its spread. Syms believes in imme- 
diate operation at any stage of appendicitis. If 
infection is present a rapid, simple operation, 
with drainage, is indicated, the drains being 
placed between the intestines and the parietal 
peritoneum. The after-treatment consists in: 
washing the stomach if there is nausea, vomiting, 
or extreme sepsis, and withholding food and 
water per mouth for 24 to 48 hours; keeping the 
patient in the Fowler position; use of the Murphy 
drip; clear by the lower bowel by enemata to 
relieve distention; no cathartics, few drugs, no 
opium; stimulation if necessary. If the pulse 
or heart is weak, the Fowler position should not 
be used. Post-operative ileus is due to spreading 
peritonitis, septic infection, excessive manipula- 
tion at the time of operation, faulty placing of 
drains, failure to empty the lower bowel before 
distention, and the use of morphine or opium. 

The principles of the Ochsner method, as out- 
lined by Hicks (60), are as follows: The medical 
treatment, if it can be called such, consists in the 
prohibition of food, physic, and generally of 
water; lavage at times; rest in bed; mild heat 
applied locally. All cases seen in the first 24 
hours are operated upon at once if willing; a 
few are operated upon on the third day; but 
cases from the fourth to ninth days, especially if 



FOWLER : THE VERMIFORM APPENDIX 



II 



very ill, are treated medically until a safer time 
for operation. 

Deaver and Pfeififer (6i) agree with Ochsner in 
their statement that early operation in appendicu- 
lar peritonitis is the rule, but is of no benefit and 
may be harmful in cases of more than 40 hours' 
duration, with signs of diffuse peritonitis and 
marked systemic toxaemia. Removal of the 
appendix is of no avail as that organ is buried in 
a mass of omentum and coils of intestines and is 
incapable of adding to the infection. Spreading 
peritonitis cannot be checked by surgical means. 
The best treatment is supplying rest to the 
alimentary tract by withholding everything by 
mouth. The Fowler position and enteroclysis 
are important. When the outlying inflammation 
subsides and localizes about the appendix the 
latter may be removed or the pus which is about 
it. The after-treatment consists in the sitting 
posture, enteroclysis, nothing by mouth, and 
careful nursing. 

ANESTHETIC 

In a consideration of choice of an anaesthetic 
Bevan (62) states that drop ether should be 
chosen today as the standard general anaesthetic 
when a prolonged anaesthesia is desired with 
relaxation and unconsciousness. Gas should 
be chosen in short anaesthesias and in special 
cases, such as kidney insufficiency. Local in- 
filtration anaesthesia may be used when the sur- 
geon has the full co-operation of the patient and 
when the field of operation can be completely 
infiltrated and anaesthetized by a safe amount 
of novocaine and epinephrin. He believes that 
nerve-blocking should as a rule be confined to 
nerves which are exposed by a dissection done 
under local infiltration, as in a herniotomy. 

Harris (63) reports 34 appendectomies done 
under nerve-blocking. The appendix is insensi- 
tive, but novocaine must be injected at the base 
of the meso-appendix. The method is safe and 
free from the dangerous sequellae of general 
anaesthesia. The psychic element has been over- 
estimated. Dread of operation is based upon 
fear of pain which may be abolished by assurance 
that there will be none; upon loss of conscious- 
ness, which does not obtain with local anaesthesia; 
and upon fear of the outcome. This fear may be 
mitigated somewhat by the fact that patients are 
apt to consider an operation which can be done 
with local anaesthesia as less severe than one 
requiring a general anaesthetic. Nerve-blocking 
teaches the surgeon to employ gentle manipula- 
tions which tends to decrease shock. 

Braun (64) says: "The writer confesses that 



after many attempts, some of them dating back 
a long time, he always returns to the same con- 
clusion; that is, to perform operations on the 
appendix under general anaesthesia without local 
anaesthesia." 

INCISION 

Our views in regard to the most desirable in- 
cision for appendix removal have recently been 
modified. Brickner (65) states that the Mc- 
Burney incision is satisfactory for a simple 
appendectomy, but a presumably simple appen- 
dectomy may resolve itself into a more extensive 
operation requiring Uberal exposure. The in- 
cision is not suitable for exploration of the upper 
abdomen, so often indicated, nor does it lend 
itself to enlargement. Its routine use would 
lead to otherwise avoidable technical difliculties, 
and conditions might be overlooked which would 
be observable through the right rectus incision. 

Harrigan (66) describes a modified McBurney 
incision for the treatment of appendicitis and 
pelvic disease as follows: (i) After removal of 
the appendix the peritoneum and internal 
oblique and transversalis muscles are sutured. 
(2) The skin incision is extended downward and 
inward toward the median line. (3) The aponeu- 
rosis of the external obHque is divided to the 
point where it fuses strongly with the anterior 
rectus sheath. (4) The anterior rectus sheath 
is incised parallel to the line of fusion of the 
external oblique muscle, leaving a sufficient mar- 
gin internally to suture. (5) The rectus muscle 
is freed, displaced, and retracted outward. 
(6) The peritoneum is incised. 

Rockey (67) describes the transverse incision 
as follows: The skin incision, 2 to 2.5 inches long, 
is made directly transverse with its center at or 
near McBurney's point. The outer part of the 
rectus sheath is incised, dividing the tendinous 
border and the aponeurosis of the muscles on a 
directly transverse line. The scalpel handle is 
inserted below and the finger above and the 
wound pulled wide apart without cutting any 
muscle fibers. The external oblique fibers are 
retracted at the outer angle and the rectus at the 
inner angle. The peritoneum is divided trans- 
versely. Definite pre-operative diagnosis is 
essential as this incision is not adapted to other 
pathological conditions. In interval cases and 
acute cases before rupture the operation is 
facilitated and firm union obtained. In pus 
cases it gives direct approach. Drainage is 
placed in the outer angle of the incision, and the 
outer side of the caecum. Rockey believes that 
liability to hernia is diminished. 



12 



INTERNATIONAL ABSTRACT OF SURGERY 



OPERATIVE TECHNIQUE 

Torek (68) has described a combined incision 
for appendectomy and right herniotomy. The 
skin incision usually employed in herniotomy is 
prolonged outward and the appendix is removed 
through a muscle splitting incision beyond the 
internal ring. 

An interesting variation of operative technique 
is described by DeTarnowsky (69). He advo- 
cates the routine removal of the appendix through 
the internal inguinal ring during right herniotomy. 
His results have been satisfactory in over 50 
cases. The caecum is distant only 4 to 6 cm. 
from the internal ring and can be partially or 
totally delivered. If the ring admits two fingers 
or can be easily stretched to admit them, he 
delivers the caecum with the index and middle 
fingers. A freely movable appendix may be 
delivered with the index finger alone. Gross 
pathology was evident in 30 per cent of the 
appendices thus removed. He does not advise 
this route in acute appendicitis. 

Neill (70) describes CuUen's method of exposing 
a retrocaecal and densely adherent appendix. 
The base of the appendix can usually be located. 
When this is accomplished blunt forceps are 
pushed through the meso-appendix at this point 
and a tape drawn through. Traction upon the 
ends of the tape brings up from three-fourths to 
one inch more of the appendix. Another tape 
is inserted as before and this maneuver repeated 
until the appendix tip is delivered. Usually 
three tapes are sufficient. The meso-appendix 
is clamped off and the remainder of the operation 
carried out according to indications. 

White (71) reports a case of appendicitis, 
drained with a rubber tube, in which an active 
haemorrhage began four days after operation and 
continued twenty-four hours, although packing 
was tightly inserted about the tube. He believes 
that the haemorrhage was produced by erosion of 
the deep epigastric artery by the drainage tube. 
Fatal haemorrhage has occurred from this source. 
The artery is frequently exposed, with its com- 
panion veins, in the incision. White applies 
two ligatures about one inch apart to these 
vessels in the lower angle of the incision. Free 
anastomosis insures adequate blood supply. He 
believes that ligation should be routine in this 
class of cases. 

Pettit (72) describes a method of drainage 
through the McBurney incision. The drainage 
tubes lie close to the ilium at the outer end of the 
spUt in the internal obHque and transversalis. 
These muscles are then sutured to the tubes. A 



slit is made in the external oblique close to the 
iHum and the tubes are drawn through. Finally, 
they are brought out through a corresponding 
small skin incision close to the anterior superior 
spine. The drainage canal is thus placed be- 
tween the caecum and the bony wall of the pelvis. 
Primary union of the operative incision is facili- 
tated. 

Benjamin (73) deprecates the practice of 
leaving the raw appendix stump uncovered, as 
adhesions are invited. Nature must cover it 
over with tissue or exudate. 

Carter (74) describes his method of disposing 
of the appendix stump as follows: The appendix 
is clamped near the base and cut off. The suture 
is threaded on a round needle. The needle is 
inserted into the caecum about one-fourth inch 
from the stump and emerges about one-fourth 
inch beyond, parallel with the base of the appen- 
dix. Repeating this maneuver twice more sur- 
rounds the stump with a triangular stitch. An 
assistant inverts the stump into the bowel and 
the suture is tied. A few reinforcing Lembert 
sutures may be inserted. 

The Mayo (75) appendectomy, so beautifully 
demonstrated by the stereoclinic of Kelly, is 
probably the best-known method. The writer 
expresses continued confidence in a procedure 
which he has previously described. 

COMPLICATIONS 

As a complication of appendicitis, Delatour 
(77) reports seven cases of pelvic abscess follow- 
ing the Fowler position. The patient does well 
for a time, although there is persistent slight 
elevation of temperature. The incision has ceased 
to drain and the patient may be allowed to go 
home with a temperature slightly above normal. 
Others suddenly recover. Delatour believes 
that all these cases have undetected pelvic 
abscesses of comparatively slight virulence. 
Sudden recovery is due to rupture of the abscess 
into the rectum. In this series the abscess was 
disclosed by rectal examination. Treatment 
consisted in incision per rectum, unless the ab- 
scess was located high up, in which event it was 
aspirated. 

Babler (78) believes that pylephlebitis with 
multiple abscesses of the lung or liver is a more 
frequent complication of appendicitis than is 
realized. In a typical case the diagnosis rests 
on: (i) the history, showing that the appendix 
was the primary seat of trouble; (2) the shifting 
of the symptoms from the appendix to the 
hepatic region ; (3) the progressive increase in the 
severity and character of the symptoms; (4) the 



FOWLER: THE VERMIFORM APPENDIX 



13 



repeated chills followed by high pulse-rate and 
marked elevation of body temperature; (5) the 
jaundice; (6) the persistent pain in the hepatic 
region; (7) the urinary and blood findings; (8) 
the change of liver dullness; (9) the picture of 
marked toxaemia; and (10) the absence of the 
signs and manifestations of extensive peritonitis. 
Multiple abscess of the lung is indicated by 
repeated chills, septic temperature, and persistent 
cough. The only hope of relief lies in locating 
and draining the abscesses. Babler reports 
three cases, two were abscesses in the liver, one 
of the lung. All were fatal. 

Markoe (79) quotes Deaver (80) as follows: 
"The earlier the operation (for appendicitis dur- 
ing pregnancy), the less the likelihood of infec- 
tion of the right tube and ovary and the less likely, 
therefore, the development of serious complica- 
tions. I have never had abortion occur in preg- 
nant women upon whom I have operated for 
acute appendicitis, unless the right uterine 
appendages were involved in the disease, and 
seldom then." Markoe believes that abortion 
in these cases is caused by undue handling of the 
uterus and adnexa. He reports two cases. 
Case I. Age 23, I-para, had had acute pain in 
the appendiceal region for some time. Examina- 
tion revealed a five month's pregnancy; there 
was acute pain a little above McBurney's point 
and some rigidity of the right rectus. Incision 
was made at McBurney's point. The appendix 
was found to be adherent to the ascending colon. 
The greatest care was taken that the uterus, 
fallopian tube, and ovary were not injured or 
manipulated, they being held to one side with a 
pad wet with normal salt solution. The appendix 
was removed. The patient made an uneventful 
recovery and four months later was delivered at 
full term. Case 2. The patient was suffering 
severely, with marked rigidity, temperature 
101° F., a white cell count of 16,000 and poly- 
nuclears 87. Immediate operation was advised 
and the advice accepted. A median incision was 
made from the umbilicus to the symphysis. The 
omentum extended down over the right tube and 
ovary, being firmly adherent to the uterus. The 
omentum was tied off, then the appendix, which 
was embedded in this mass, was tied off and the 
stump buried. This left a mass consisting of a 
piece of omentum, right tube, ovary, and appen- 
dix attached to the uterus and right broad liga- 
ment. The right tube was very gently tied off 
and cut away, and the adhesions which held 
the appendix, omentum, and ovary were then 
removed from the uterus. Stab wound drainage 
was provided. The patient aborted with a 4.5 



months' foetus, within twelve hours of operation. 
Otherwise her recovery was uneventful. Markoe 
states that the appendix is not drawn up into the 
abdominal cavity by pregnancy, but on the con- 
trary, may be brought up with difficulty into the 
incision. 

Wallace (81) reports a case of ruptured appen- 
dix at full- term pregnancy as follows: The pa- 
tient called him at night for supposed labor 
pains. He found her sitting up and complaining 
of severe pain low down on the right side. There 
was slight cervical dilatation. The head was 
not engaged. The next afternoon she was still 
in pain and had been continuously. Tempera- 
ture 103.6° F., pulse 128. Vaginal examination 
revealed no increase of dilatation, but signs of 
abscess in the appendix region. An ice-cap was 
applied in the hope that operation could be de- 
layed until after delivery. The next day the 
temperature was 104° F., pulse 140. Appen- 
dectomy was performed and the abscess drained. 
The incision was closed with exceptional care 
about the drains in order to withstand the severe 
strain of labor. Closure was difficult and he 
believes would have been impossible had he not 
incised the fascia transversely. The next day, 
after one and one-half hours of labor, a normal 
delivery was accompHshed under anaesthesia. 
Recovery was uneventful. The dislocation of 
McBurney's point in the pregnant abdomen was 
noticeable. It was difl&cult to determine where 
to make the incision. 

SEQUELA 

Bunts (82) reports an interesting sequela of 
appendectomy. The patient was a nurse who 
had had a clean appendectomy performed several 
years previously. She was free from discomfort 
for nearly a year after operation when she 
again complained of pain in the right side. The 
attacks were very severe. Examination revealed 
a somewhat enlarged ovary. At operation the 
right ovary was found slightly enlarged and 
cystic. At the site of the former purse-string 
suture on the caecum was a white ring which 
formed the base of a conical projection of the 
bowel about one inch in length. Fearing the 
possibility of rupture of this thin-walled diver- 
ticulum and that distention of it might cause 
colic, Bunts invaginated the protrusion into the 
caecum and secured it with a double purse-string 
suture. There has been no recurrence of pain. 
He has since found the same condition in two 
other cases, but in lesser degree. In all three 
cases the right ovary was abnormal and might 
have accounted for the pain of which they all 



14 



INTERNATIONAL ABSTRACT OF SURGERY 



complained. He believes the condition to be 
not uncommon and that future observation will 
prove it to be responsible for recurring pain in 
the right side after appendectomy. 

Case (83) states that a common cause of caecal 
stasis is adhesions, usually associated with disease 
of the appendix. Immediately following recovery 
from appendectomy there is usually considerable 
caecal stasis. Following the attempt to expel the 
barium enema, it is seen that the caecum has 
failed to contract, the peristaltic waves which 
evacuate the large bowel commencing at or above 
the ileocaecal junction instead of at the tip of the 
caecum. Even several years after operation 
caecal stasis persists in many cases, a round residue 
of barium the size of a 25-cent piece remaining 
in the caecum after the colon is otherwise emptied 
of barium. This is especially likely to occur 
where the patient complains of a tenderness of 
the caecum. Sometimes this caecal stasis was 
present before the operation, but often exists 
after operation where it did not exist before. 
He believes that the rounded barium occurs at 
the site of the stump of the appendix and that 
it has some relation to the invaginating suture 
by which the stump is buried. This suggests 
the desirability of including the least possible 
amount of caical muscularis in the suture. 

In a series of 276 cases of intestinal obstruction 
reviewed by McGlannan (84), 63 were post- 
operative. Nearly 40 per cent of the post- 
operative obstructions and 10 per cent of all 
cases in this series followed drainage operations 
for appendicitis. This is a potent argument in 
favor of early operation at a time when no drain- 
age is required. Had these patients been oper- 
ated upon early, all would have been spared a 
second operation, as a result of which 9 died. 
Prompt operation in appendicitis and careful 
covering of surfaces in all abdominal operations 
will afiford efficient prophylaxis against post- 
operative obstruction. 

In a series of cases of acute intestinal obstruc- 
tion reported by Deaver and Ross (85), 81 were 
due to post-operative adhesions. Fifty-one cases 
followed operations for appendicitis and 44 were 
drained at the original operation; 27 died. 

PROGNOSIS 

The prognostic value of post-operative leu- 
cocyte count is discussed by White (86). He 
states that a secondary peritoneal infection with 
good resistance shows an early and marked in- 
crease of leucocytes and will continue for some 
time. The leucocyte count is a safe guide as to 
conditions within the abdomen. In general 



peritonitis a constant low or declining leucocyto- 
sis denotes a grave prognosis. 

Eisner (87) believes that an unusual amount 
of urobilinogen in the urine during appendicitis 
indicates a destructive lesion of the appendix. 

MORTALITY 

Turner (88) states that the mortality of appen- 
dicitis should be less than 5 per cent. Early 
operation would decrease the death-rate to i or 
2 per cent, or it might become practically nil. 
Appendicitis is not inherently dangerous. The 
result is a question of degree of peritonitis and 
the stage of the disease when operated upon. 
At present over 60 per cent of cases are operated 
upon when involvement is localized. Ten years 
ago conditions were reversed. 

Kakels (89) believes that the majority of 
deaths from appendicitis are due to failure in 
making a diagnosis, the abdominal pain being 
assigned to other abdominal organs rather than 
the appendix. Early diagnosis should be easy if 
we remember the following train of symptoms: 
sudden, generahzed abdominal pain, gradually 
becoming localized, nausea and vomiting, general 
abdominal sensitiveness, local rigidity, elevation 
of temperature, leucocytosis, and rapid pulse. 

Murphy (90) makes the startling statement 
that the mortality of appendicitis in the hospitals 
of the United States is 10 per cent. This death- 
rate is due to procrastination. The early symp- 
toms are usually diagnostic, later they are 
obscure. Early symptoms are no guide to the 
probable outcome. Pain and temperature may 
be gone by the second day which may mean 
resolution or gangrene. A gangrenous appendix 
produces neither pain nor leucocytosis. The 
next symptoms are those of general peritonitis. 
The mortality in childhood is three or four times 
as high. 

CONCLUSIONS 

1. The incidence of primary carcinoma of the 
appendix suggests the advisability of routine 
appendectomy during laparotomy. 

2. Infection of the appendix by bacteria car- 
ied through the blood stream from a distant 
focus is an established fact. 

3. Typhoid fever and pneumonia, in their 
early stages, may be difficult to differentiate from 
acute appendicitis. 

4. The chief symptoms of chronic appendicitis 
may be referred to the epigastrium. 

5. Undue retention of barium in the appendix 
and tenderness of that organ elicited under 
visualized palpation are roentgen signs of great 
diagnostic value. 



FOWLER: THE VERMIFORM APPENDIX 



IS 



6. Appendicular obliteration is an end-result 
of inflammatory changes and is itself productive 
of symptoms. 

7. Excepting the frank case of acute appen- 
dicitis, diagnostic uncertainty or coincident 
pathology demand ample incision; hence the 
right rectus approach. 

8. The mortality of appendicitis is too high. 
Early diagnosis and early operation are essential 
to low mortality. 

REFERENCES 

1. ScHRtJP. Left-sided appendicitis. Surg., Gynec. & 

Obst., 191S, xxi, 442. 

2. Corner. Quoted by Schrup. 

3. Palamountain. Gangrenous appendicitis on the 

left side. J. Am. M. Ass., 1915, Ixiv, June 12. 

4. Wade. Report of case of congenital inguinal implan- 

tation of the appendix. J. Am. M. Ass., 1915, 
Ixiv, March 6. 

5. Heile. Physiology of the appendix. Beitr. z. 

klin. Chir., 1914, xciii, 520. 

6. Waller and Cole. The appendix. Surg., Gynec. 

& Obst., 1915, xxi, 750. 

7. GuNN and Whitelocke. Movements of the appen- 

dix. Brit. J. Surg., 1914, i, July. 

8. RosENOW. Bacteriology of appendicitis and its 

production by intravenous injection of streptococci 
and colon bacilli. J. Infect. Dis., 1915, March. 

9. RosENOW. Elective localization of streptococci. 

J. Am. M. Ass., 1915, Ixv, Nov. 13. 

10. Anderson. Appendicitis as a sequela of tonsil- 

litis. Am. J. M. Sc, 1915, Oct. 

11. Savini. Contribution to the study of chronic ap- 

pendicitis. Med. Rec, 1915, April 3. 

12. Hughes. Cause of appendicitis. Brit. M. J., 1915, 

May 29. 

13. Battle. The black (pigmented) appendix. Lancet, 

Lond., 1915, Jan. 23. 

15. SuztJKi. R61e of oxyuris in etiology of appendicitis. 

Surg., Gynec. & Obst., 1915, xxi, 702. 

16. Sherrick. The relation of trauma to appendicitis. 

111. M. J., 191S, Feb. 

17. Stickney. a case of myoma of the appendix. Bull. 

Johns Hopkins Hosp., 1915, Aug. 

18. Meyer. Primary carcinoma of the appendix. 

Surg., Gynec, & Obst., 1915, xxi, 354. 

19. Rassieur. Primary carcinoma of the appendix. 

J. Mo. St. M. Ass., 1913, Dec. 

20. Phemister. Pseudomucinous cyst of the appendix. 

J. Am. M. Ass., 1915, Ixiv, May 29. 

21. Ogilvie. Pseudomyomatous cyst of the appendix. 

J. Am. M. Ass., 1915, Ixiv, Feb. 20. 

22. Pfeiffer. Appendicular obliteration. Ann. Surg., 

Phila., 1915, Ixii, April. 

23. Bonn. A series of filiform appendices. Surg., 

Gynec. & Obst., 1915, xxi, 78. 

24. Eastman. Quoted by Bonn. 

25. JxiDD. A specimen of auto-amputation of the ap- 

pendix. J. Am. M. Ass., 1915, Ixv, Oct. 2. 

26. Murphy. Quoted by Judd. 

27. Randall. Rigidity of right external oblique in ap- 

pendicitis. J. Am. M. Ass., 1915, Ixiv, June 5. 

28. Ten Horn. A new diagnostic sign of appendicitis. 

Zentralbl. f. Chir., 19 14, Oct. 3. 

29. Ruthkevitch. Diagnosis of chronic appendicitis. 

Russk. Vrach, 1915, March 21. 



30. BiscHOFF. Differential diagnosis of chronic ap- 

pendicitis. Monatschr. f. Geburtsh. u. Gynaek., 

1914, Sept. 

3 1 . Lanz. Symptoms in genital organs with appendicitis. 

Zentralbl. f. Chir., 1914, Nov. 28. 

32. Sutton. An unusual complication of acute appen- 

dicitis. N. Y. M. J., 1915, Oct. 30. 
2S- Randolph. Sciatica: a symptom of appendicitis. 
J. Am. M. Ass., 1915, Ixiv, Feb. 13. 

34. Eisen. Roentgenoscopic evidence in appendicitis. 

N. Y. M. J., 191S, Aug, 14. 

35. Imboden. Roentgen diagnosis of lesions of vermi- 

form appendix. Am. J. Roentgenol., 1915, Jan. 

36. McWiLLiAMS. Reflex disturbances due to chronic 

appendicitis. Med. Rec, 1914, Dec. 26. 

37. MoRLEY. Some conditions that simulate chronic 

appendicitis. Lancet, Lond., 1915, Jan. 9. 

38. LoNGO. Pseudo-appendicitis. Policlin., Roma, 1915, 

May. 

39. Kenefick. Chronic appendicitis: its relation to 

cardio and other neurospasms. N. Y. M. J., 

1915, Aug. 28. 

40. Aaron. Chronic appendicitis, pylorospasm, and 

duodenal ulcer. J. Am. M. Ass., 1915, Ixiv, May 29, 

41. Aynesworth. Acute appendicitis in children. Am. 

J. Obst., 1915, Nov. 

42. Fleischner. Error in the diagnosis of lobar pneu- 

monia. Arch. Pediat., 1915, March. 

43. Gage. Acute appendicitis in typhoid. Ann. Surg., 

Phila., 1915, Ixii, Aug. 

44. Stokes and Arnick. Quoted by Gage. 

45. Winslow. Diagnosis of appendicitis in early ty- 

phoid. Ann. Surg., Phila., 1915, Ixii, Nov. 

46. Sappington. Possibility of failure in prophylactic 

typhoid vaccination. J. Am. M. Ass., 1915, Ixiv, 
June 26. 

47. Wolfsohn. Appendicitis and typhoid. Berl. klin. 

Wchnschr., 1915, Aug. 16. 

48. Cabot. Stones in the kidney and ureter. J. Am. 

M. Ass., 1915, Ixv, Oct. 9. 

49. Braasch and Moore. Stones in the ureter. J. 

Am. M. Ass., 1915, Ixv, Oct. 9. 

50. Gage. Acute tubercular inflammation of the ileo- 

colic glands simulating appendicitis. Boston M. 
& S. J., 1915, Aug. 26. 

51. Watson. A case of obstruction of Meckel's diver- 

ticulum. J. Am. M. Ass., 1915, Ixiv, Feb. 13. 

52. Strode. Report of four cases of Meckel's diverticuli- 

tis. J. Am. M. Ass., 191S, Ixv, Aug. 21. 

53. RiGGS. Effusion into bowel wall simulating appendi- 

citis. Northwest Med., 1915, May. 

54. Waller. Appendiceal inflation. J. Am. M. Ass., 

1914, Sept. 5. 

55. Strauss. Extraperitoneal appendix vermiformis. 

Surg., Gynec, & Obst., 1915, xxi, 318. 

56. Eighty. Appendicitis as seen by the internist; re- 

port based upon about 700 cases. Penn. M. J., 
i9iS,Jan. 

57. Guthrie. Appendicitis treated with anti-colon 

bacillus serum and vaccine. Lancet, Lond., 

1915, Jan. 9. 

58. Syms. Treatment of appendicitis. N. Y. M. J., 

1914, April 18. 

59. Stanton. Sequence of pathologic changes in acute 

appendicitis and appendicular peritonitis. Am. 
J. M. Sc, 1915, AprU. 

60. Hicks. Appendicitis: an appreciation of the Ochsner 

method. Canad. M. Ass., J., 1915, Sept. 

61. Deaver and Pfeiffer. Peritonitis. N. Y. M. J., 

1915, Nov. 13. 



i6 



INTERNATIONAL ABSTRACT OF SURGERY 



62. 
63. 

64. 
6s. 

66. 
67. 



69. 



70. 



71- 



72. 

73- 

74. 

75- 
76. 



Bevan. The choice and technique of the anaesthetic. 77. 
J. Am. M. Ass., 1915, Ixv, Oct. 23. 

Harris. Nerve-blocking. Surg., Gynec. & Obst., 78. 
i9iS,xx, 193. 

Braun. Braun and Shields', Local Anaesthesia, p. 303. 79. 

Brickner. The McBurney incision. Am. J. Surg., 
1915, Jan. 

Harrigan. Modified McBurney incision. Surg., 80. 
Gynec. & Obst., 1915, xxi, 782. 81. 

RocKEY. Transverse incision in operation for ap- 
pendicitis. J. Am. M. Ass., 1915, Ixv, Sept. 11. 82. 

Torek. Combined operation for the removal of the 
appendix and the cure of right inguinal hernia. 
Ann. Surg., Phila., 1906, May. 83. 

DeTarnowsky. Appendectomy through the right 
inguinal canal. J. Am. M. Ass., 1915, Ixv, Oct. 30. 84. 

Neill. Exposure of appendix by Cullen's method. 

J. Am. M. Ass., 1915, Ixiv, Jan. 23. 85. 

White. A modification of the technique in the opera- 
tion for suppurative appendicitis, based on post^ 
operative haemorrhage. Surg., Gynec. & Obst., 86. 
1914, xix, 679. 

Pettit. a method of drainage in suppurative ap- 87. 
pendicitis. Surg., Gynec. & Obst., 1914, xix, 794. 

Benjamin. Intra-abdominal complications. J. Am. 

M. Ass., 1913, Ixi, Dec. 6. 88. 

Carter. New method of disposing of stump of ap- 
pendix. South. M. J., 1915, May. 89. 

JuDD. Mayo appendectomy. Kelly's Stereo-Clinic. 

Fowler. A single stitch appendectomy. Med. 90. 
Rec, 1915, Sept. 25. 



Delatour. Abscess following the Fowler position in 
appendicitis. N. Y. M. J., 1915, Feb. 13. 

Babler. Pylephlebitis complicating appendicitis. 
Ann. Surg., Phila., 1915, Ixii, May. 

Markoe. a report on two cases of appendicitis 
complicating pregnancy. Bull. Lying-in Hosp., 
N. Y., 1915, March. 

Deaver. Quoted by Markoe. 

Wallace. Ruptured appendix at full-term preg- 
nancy. J. Am. M. Ass., 1915, Ixiv, Feb. 27. 

Bunts. Traumatic diverticulum of caecum follow- 
ing appendectomy. Surg., Gynec. & Obst., 1914, 
xix, 791. 

Case. Post-operative roentgenography. J. Am. M. 
Ass., 1915, Ixv, Nov. 6. 

McGlannan. Intestinal obstruction. J. Am. M. 
Ass., 1915, Ixv, August 21. 

Deaver and Ross. Mortality statistics of two hun- 
dred and seventy-six cases of acute intestinal ob- 
struction. Ann. Surg., Phila., 1915, Feb. 

White. Post-operative leucocyte count with especial 
reference to appendicitis. Wash. M.Ann. ,1914, Sept. 

Eisner. High urobilinogen content in urine in ap- 
pendicitis, a sign of destructive lesions. Ztschr. f. 
Chir., cxxxii, Nos. 5 and 6. 

Turner. The mortality of appendicitis. Brit. M. 
J., 1915, June 12. 

Kakels. The operative mortality of appendicitis. 
N. Y. M. J., 1914, April 18. 

Murphy. A talk on appendicitis. Surg. Clin. J. B. 
Murphy, Chicago, 1915, June. 



ABSTRACTS OF CURRENT LITERATURE 



GENERAL SURGERY 



SURGICAL TECHNIQUE 



OPERATIVE SURGERY AND TECHNIQUE 

Primrose, A. : The Physics of a Surgical Dressing, 
with Special Reference to the Harmful Effect 
of Using Impermeable Material Over Septic 
Wounds. Brit. M. J., 1916, i, 238. 

The author refers to an article by Sir Almroth 
Wright in which Wright advocates the use of sodium 
chloride 5 per cent with sodium citrate 0.5 per cent 
as a solution for moist dressings, these being cov- 
ered by an impervious covering. The author 
objects to the use of an impervious covering over 
moist dressings where drainage is desired. He 
cites experiments to show that capillary attraction 
is lessened or made nil when evaporation from part 
of the dressing is prevented. The experiments were 
carried out by using flasks containing water, a 
gauze wick being saturated and placed therein with 
one end protruding. A crystal of an aniline dye 
was then placed in the wick. If the flask was 
uncovered the dye rose in the wick; whereas, if an 
impermeable substance was placed over the flask 
the dye did not rise. This objection to Wright's 
recommendation, says the author, is especially 
tenable where the wound is an infected one where 
drainage is greatly to be desired. J. H. Skiles. 

Fisher, H. E.: Non-adhering Surgical Gauze. 

/. Am. M. Ass., 1916, Ixvi, 939. 

Fisher has experimented with various materials 
in the dressing of open wounds. Absorbent cotton, 
chamois skin, and powders he rejects as unsatis- 
factory. Gutta-percha and silver foil, if perforated, 
^ive fairly good results. Plain surgical gauze is 
satisfactory, except that it adheres to granulating 
wounds, a disadvantage which is less troublesome if 
narrow mesh gauze is used. Medicated gauze he 
found to have no particular advantage over plain 
gauze. 

He secured the best results from the use of gauze 
impregnated with paraffin in the following manner: 
Eight parts of paraffin mixed with two parts of white 
petrolatum and lanolin is boiled for ten minutes. 
Then dry-sterilized gauze, in strips, is immersed 
for ten minutes in the mixture. The gauze is 
gradually removed and stretched, and allowed to 
■dry in a current of filtered air, which frees the aper- 
tures of excess paraffin. In use, one layer or two 
is placed in direct contact with the wound or raw 



surface, and ordinary surgical gauze fluffed is placed 
above it. This gauze can be changed as frequently 
as desired and the waxed gauze can be left on 
for a considerable period. As the wound heals it 
is lifted off. 

The author finds that this method of dressing has 
the following advantages: (i) It does not adhere 
to a granulating wound, and can be left on for a 
considerable period. (2) It causes no pain or dis- 
comfort on application or removal. (3) The paraffin 
is not absorbed, and the gauze does not become 
matted with secretions and debris. (4) It closely 
conforms to the surface to which it is applied. (5) 
It allows adequate drainage of the wound secretions 
through the meshes. (6) It is easily and quickly 
sterilized by immersion in absolute grain alcohol. 
(7) It is of particular value in the treatment of skin- 
grafts. Albert Ehrenfried. 

ASEPTIC AND ANTISEPTIC SURGERY 

Fraser, J., and Bates, H. J.: The Surgical and 
Antiseptic Values of Hypochlorous Acid (Eusol) . 

Edinb. M.J., 1916, xvi, 127. 

The method of preparation of eusol is as follows: 
In a quart bottle 27 gm. of dry bleaching powder 
are placed, i liter of water added to this and the 
mixture shaken. Then 27 gm. of boric acid are 
added and the bottle filled with water; after standing 
for a few hours the mixture is filtered. The filtrate 
is eusol and contains about 0.5 per cent hypochlorous 
acid. 

Gunshot or stab wounds packed with gauze 
soaked in eusol solution show beginning granulations 
within 56 hours. The objections made to the use 
of this solution are the pain it causes, the irritated 
and soiled condition of the surrounding skin, and 
the arrest of wound secretion. According to the 
authors, all of these objections are negligible. 

The solution has been used with inestimable 
benefit in gas gangrene, and in compound fractures 
complicated by infection, in disintegration of joints, 
in compound fractures of the skull, in empyema, 
and after inflammation or wounds of the abdominal 
cavity, eusol has been of benefit in preventing sup- 
puration and arresting infection. A number of 
cases of acute toxaemia subsequent to wound in- 
fection with a gas-producing organism have been 
treated by intravenous injection of eusol in amounts 



17 



INTERNATIONAL ABSTRACT OF SURGERY 



varying from 40 to 70 ccm., to which was added 
sodium chloride in the proportion of 0.85 per cent. 
With this method of treatment most gratifying 
results have been obtained. E. K. Armstrong. 

Clinical Report on the Application of Eusol; Report 
to Medical Research Committee. Lancet, Lond., 
1916, cxc, 356. 

The Medical Research Committee of the Royal 
College of Surgery of Edinburgh has presented a 
very interesting report on the use of eusol in the 
treatment of wounds. Several cases are cited to 
illustrate the use of the solution in both aseptic and 
septic wounds and to illustrate its value in serous 
and synovial cavities and in inflammatory lesions 
of various types. They advocate its usefulness 
in wounds which have become septic after certain 
operations. 

Their general conclusions are that eusol in a great 
variety of cases has proved to be non-toxic and 
non-irritating, as well as an efiicient antiseptic. 
The action of eusol depends upon the free hypo- 
chlorous acid which is liberated by the eusol. There 
is also a sufficient quantity of biborate of calcium 
to give the solution a slightly alkaline reaction. 
This feebly alkaline solution can be introduced 
into wounds or serous cavities with perfect safety. 
It can even be left in such cavities in quantity with- 
out any harmful effect. In lacerated and contused 
wounds, and in compound fractures, such as are 
met with in military practice, the committee found 
it to be the most efficient antiseptic. 

It is most efficacious during the period of what 
might be termed progressive sepsis. Some surgeons 
have emphasized the benefit of modifying the treat- 
ment when sepsis is subsiding or has ceased. The 
granulations form after a period of two to three 
days and rapidly cover the surface of the wound. 
Any tendency to superabundant growth of granula- 
tions and consequent delay in healing can be coun- 
teracted either by so applying the eusol that the 
serous discharge is reduced to a minimum and the 
wound kept dry, or by discontinuing eusol and using 
other dressings appropriate for healing wounds. 
In any event the sepsis is by this stage completely 
under control. 

The freedom which can be exercised in, the applica- 
tion of eusol, and the rapid action which it has in 
arresting the sepsis and discharge of an infected 
wound, led to experiments on the effect of eusol on 
the blood. Following this, eusol was employed in 
the treatment of general sepsis toxaemia by intra- 
venous injection. 

This method was first made use of by Lorrain 
Smith, Ritchie, and Rettie, in a case of grave 
puerperal septicaemia, and the result was the recov- 
ery of the patient. They have also applied the 
treatment in other similar conditions. In several 
cases toxaemia has been successfully overcome, and 
although such a result has not been uniformly 
attained, the safety of the method justifies its being 
applied in the diseases referred to in their pre- 



liminary communication. Intravenous injection 
has also been applied with success by Captain 
Eraser and Captain Bates in cases of acute toxaemia 
secondary to gas gangrene. 

Further research is now being carried out on the 
development of the subject foreshadowed by these 
investigations. 

The lotion is exceedingly inexpensive. The 
ingredients are procurable anywhere at a slight 
cost, and the preparation is a very simple process. 
Eupad powder is composed of equal weights of 
boric acid and bleaching powder. The boric acid 
is in sufficient excess to set free the hypochlorous 
acid in the solution. The bleaching powder should 
be dry and should contain 28 to 30 per cent available 
chlorine. 

The solution eusol is prepared as follows: Add 
to I liter of water 25 grams of the powder; shake 
well and allow it to stand an hour, then filter. The 
clear solution is eusol, and contains about 0.5 per 
cent hydrochlorous acid. If the bleaching powder 
is old or not up to the strength given above, use a 
larger quantity of the powder. 

A rough and ready method of preparation is to 
add one-half ounce of the mixed powder to i pint 
of water; stir or shake and allow the sediment to 
settle. D. C. Balfour. 

AN.ffiSTHETICS 

Jackson, D. E. : Some Observations on Ansesthesia 
and Analgesia. /. Pharmacol. 6* Exp. Therap., 
1916, viii, 113. 

Jackson calls attention to the fact that for a num- 
ber of years past, nitrous oxide has been constantly 
growing in favor as a general anaesthetic and anal- 
gesic. This has been made possible mainly, he 
states, by the introduction of improved methods of 
administration. The duration of the anaesthesia 
under nitrous oxide has also progressively increased 
from an average of only a minute or two up to an 
average of perhaps ten minutes or longer, and Jack- 
son states that he has been able by an improved 
method to keep dogs anaesthetized for periods up to 
five and one-half hours. Quite recently, he states, 
there has been a slight tendency to avoid the use of 
nitrous oxide in any prolonged operation (half an 
hour or more), because it has frequently appeared 
that the after-effects of prolonged nitrous-oxide 
anzesthesia were more deleterious than those of 
ether. He believes that this is mainly due to the 
use of improper and unscientific methods of ad- 
ministering the nitrous oxide. He maintains that 
the cost of nitrous oxide by the method which he 
has made use of, may be reduced to about 30 or 35 
cents per hour for the human subject. 

George E. Beilby. 

Walter, W. : An Apparatus for the Administration 
of Gas-Oxygen. N. Y. M. J., 1916, ciii, 352. 

A new apparatus is offered which combines sim- 
plicity, portability, efficiency, freedom from pres- 



GENERAL SURGERY — SURGICAL TECHNIQUE 



19 



sure, addition of humidity, accuracy, the washing 
of gases, the warming of gases, visual evidence of 
the ratio between the gases and a provision for re- 
breathing with or without ether sequence and with- 
out the removal of the mask. The gases are passed 
through warmed water by means of respective tubes 
and the evidence of the quantity of gas is shown by 
the levels of the water in these tubes. A table of 
ratios is placed in view between the gas-tubes and 
for any given volume of nitrous oxide, as evidenced 
by the level, the desired percentage of oxygen for 
that particular level may be read and instantly pro- 
vided by readjustment of the oxygen valve. The 
apparatus is illustrated and the technique of its 
application fully described in the original article. 

E. K. Armstrong. 

Aikins, W. H. B.: The Advantages and Risks of 
Combined Local and General Anaesthesia. 

Canad. Pract. &* Rev., 1916, xli, 96. 

The author limits his discussion of the use of 
combined local and general anaesthetics to opera- 
tions about the nose and throat. Hewitt's tabula- 
tion of advantages claimed for such a combination 
are: 

1. The elimination of the element of fear, to 
which a certain number of anaesthetic deaths are 
due. 

2. The production of a somnolent or apathetic 
condition, which facilitates anaesthesia. 

3. The absence of excitement during anaesthetiza- 
tion. 

4. A diminution of the amount of the general 
anaesthetic necessary to produce the necessary 
relaxation and depth of anaesthesia. 

5. The diminution of secretion, especially that 
of mucus under ether. 

6. Lessening of the tendency to vomiting and 
pulmonary complications. 

7. Lessening of the tendency to shock. 

8. A longer period of insensibility after the end 
of the operation, reducing the discomfort and pain. 

Adrenalin and cocaine, the only local anaesthetics 
considered in this article, must be used with great 
care and discrimination. They should be applied 
at least one hour before the induction of general 
anaesthesia. 

Many authors are quoted who have observed 
sudden death follow the injection of cocaine- 
adrenalin solutions during a chloroform anaesthesia. 
Dr. Goodman Levy has been able to produce 
ventricular fibriUation in cats almost at will by in- 
fections of adrenalin during chloroform anaesthesia, 
a phenomenon which has not followed ether anaes- 
thesia. Whether or not the disturbances noted are 
due to rapid absorption of adrenalin from the sub- 
mucous tissues or to direct injection into a vein has 
yet to be determined. But the undoubted risk of 
using cocaine and adrenalin in combination with 
general anaesthesia induced either completely or in 
part by chloroform has been definitely proved. 
The author concludes with an emphatic protest 



against such a combination of local with general 
anaesthesia. E. Fischel. 

Hanes, G.: Spinal Anaesthesia. Louisville Month. 
J., 1916, xxii, 289. 

The author bases his discussion upon 26 rectal 
cases which he has observed. He claims that the 
advantages of spinal anaesthesia over all other 
methods are that it causes the most perfect relaxa- 
tion of the parts which it is possible to obtain and 
that the patient has less post-operative discomfort. 
In the discussion of the technique, the usual points 
are emphasized: the proper type of needle (short, 
sharp point), an all-glass sytinge, the proper point 
for injection, the upright position of the patient, 
and the proper strength of solution. He has used 
novocaine in all his cases, one-half to one and one- 
half grain solutions being the dose employed. 

The operations were for haemorrhoids, fistulae, 
strictures, polypi, ulceration, one colostomy, and 
three cancers. The colostomy case was not suflS- 
ciently anaesthetized with one-half grain novocaine 
to permit the operation to be completed without the 
addition of ether. One patient who was operated 
upon because of a great deal of pain in the rectum 
was given one and one-half grains of novocaine. 
Although kept in the upright position, within five 
minutes respiration had ceased and no evidence of 
circulation could be observed. Under various 
stimulants the patient again had good pulse and 
respiration, but he died within twenty-four hours 
without regaining consciousness. Post-mortem 
examination showed marked disease of all the vital 
organs, which should have been sufiicient reason 
for prohibiting any form of operation. With these 
two exceptions the author's experience with spinal 
anaesthesia was completely successful and he is 
convinced of its superiority in rectal operations. 

E. Fischel. 

Lewis, B,, and Bartels, L.: Caudal Anaesthesia 
in Genito-urinary Surgery. Surg., Gynec. d' 
ObsL, 1916, xxii, 262. 

This is the method of anaesthesia proposed and 
first used by Laewen, and is based on the use of 
saline injections into the sacral canal, suggested 
by Cathlin in 1901. It is a nerve-blocking method 
of local anaesthesia, applied in the sacral canal, using 
a combination of novocaine, potassium sulphate, 
and adrenalin as the local sedative fluid. At the 
time of the making up of the report the authors 
had used the method in 85 cases; and with such 
success that they felt justified in making the report. 

This method is to be distinguished from that of 
spinal anaesthesia in that the solution is not in- 
jected into the spinal canal. The spinal canal is 
separated from the sacral canal by the cuff of dura 
mater which closes down on the cauda at about the 
first segment of the sacrum. An injection of fluid, 
therefore, into the sacral canal does not reach up 
into the spinal canal. The object of the injection 
serves to obtund the sensibilities or anaesthetize 



20 



INTERNATIONAL ABSTRACT OF SURGERY 



the nerves issuing from the anterior sacral foramina 
that form the sacral plexus. One of the most im- 
portant nerves of this plexus is the pudic, distrib- 
uted to the bladder and prostate and other genito- 
urinary organs. By anaesthetizing this nerve an 
anaesthetic condition of the organs mentioned is 
secured. 

Directions for preparing the solution are given 
and the authors' experience with dosage is de- 
tailed. It was found preferable to use larger quan- 
tities of weaker solution rather than small quan- 
tities of stronger solution to obtain the anaesthetic 
effect. It was found that the pressure-effect of 
the anaesthetizing fluid was strongly influential 
in securing success. From 50 to 90 ccm. of the 
fluid is now being used by the authors. 

The method is particularly advantageous in 
the very debilitated, decrepit, and aged patients 
who require major work in genito-urinary surgery. 
Prostatectomies done suprapubically, removal of 
vesical stones, and cystoscopies in hypersensitive 
individuals, have all been done with marked suc- 
cess and comfort under this method of anaesthesia. 

The technique of the administration is described 
and illustrated in the original article. Measures 
for preventing untoward effects, such as introducing 
the needle into the spinal canal or into a vein, are 



described and suggestions given for avoiding such 
effects. 



SURGICAL INSTRUMENTS AND APPARATUS 

Bergeron, J. Z.: Pillar- Compression Forceps for 
Controlling Haemorrhage Following Tonsil- 
lectomy. /. Am. M. Ass., 1916, Ixvi, 505. 

The forceps devised by the author for compres- 
sion of the pillars after tonsil enucleation, consist 
of (i) a handle, (2) a lock, (3) a goose-neck shank, 
and (4) compression tips. A companion forceps 
which has a straight shank is also described, the 
two to be used together; the curved forceps to be 
applied above and the straight forceps below. 
The curved forceps are so constructed that the han- 
dle lays outside of the mouth, sufficiently to the 
side to permit work on the other tonsil or the 
adenoids while the compression continues. 

The point of chief importance in applying the 
forceps is to pass the compression tips to a suffi- 
cient distance toward the lateral wall of the throat, 
so as to include in the bite (i) that portion of the 
posterior pillar next to the constrictor of the 
pharynx, (2) the floor of the tonsillar fossa, and 
(3) that portion of the anterior pillar next to the 
mucosa of the cheek. Otto M. Rott. 



SURGERY OF THE HEAD AND NECK 



HEAD 
Gray, H. M. W. : Observations on Gunshot Wounds 
of the Head. Brit. M. J., 1916, i, 261. 

The principles in the treatment of these wounds 
as deduced by Gray are as follows: (i) Infected gun- 
shot wounds of the skull and brain require more 
careful consideration and prompt attention than 
similar wounds of any other part. (2) Sepsis can 
best be combated and prevented by early and com- 
plete operations. (3) Permanent disability can 
be prevented in most cases by the systematic re- 
moval of foreign material or displaced bone from 
the surface or substance of the brain whenever 
these are accessible to legitimate surgery. (4) 
By these precautions the immediate results in the 
saving of life and more rapid restoration of function, 
when possible, are better than those obtained by 
more conservative procedures. 

The presence of any foreign body in the brain 
may not cause immediate disability but sooner or 
later the brain is very apt to resent the presence of 
these bodies and untoward symptoms develop. 
Fragments of bone, clothing, metal, etc., should 
therefore be removed as soon as possible after the 
receipt of the injury. The presence or absence of 
cerebral or cerebellar symptoms should not, in 
the average case, deter the operator from the 
radical treatment of these wounds. 

In minor injuries, the lacerated scalp should be 
excised and sutured. Primary union usually results. 



In depressed fractures of the inner table contusion 
of the brain is almost certain to occur. The dura 
should be opened in all such cases, even when it is 
apparently normal, otherwise injuries to the brain 
substance may be overlooked and scar tissue form 
which may cause future trouble. Furthermore, 
the injured brain substance, if allowed to remain 
untouched, may become infected and cause abscess, 
encephalitis, or meningitis. When wounds of the 
blood sinuses are present it is thought advisable to 
remove depressed fragments of bone for two rea- 
sons: (i) Their retention may cause obstruction to 
the return of blood from some part of the brain or 
(2) may lead to septic thrombosis. 

As to drainage of the brain, as a general rule this 
should be avoided whenever possible. The pres- 
ence of definite pus, infected blood-clot, of inacces- 
sible definitely infected foreign bodies, or profuse 
oozing would indicate drainage. Bacteriological 
examination of removed substances should be made 
and if streptococci are found the drainage should 
be maintained until these disappear from the dis- 
charges or become very few in number. 

Several points are enumerated by the author: 
(i) There may be multiple injuries, therefore the 
whole scalp should be shaved. (2) The force caus- 
ing the injury usually results in local injury; injury 
by contre-coup has rarely to be considered. (3) 
Fracture of the inner table almost always means 
injury to the brain substance. (4) A complete 



GENERAL SURGERY — SURGERY OF THE HEAD AND NECK 



21 



operation facilitates repair, gives better immediate 
results, and tends to prevent troublesome sequela? 
more surely than an incomplete one. (5) Death 
is due in practically all cases to the effect of sepsis 
on the damaged brain. (6) The aim in all operations 
should be to remove as much infected material 
and tissue as is feasible. (7) Foreign bodies act 
deleteriously in four ways: by direct effect on 
delicate brain substance, favoring sepsis, interfering 
with circulation, and causing scar formation. (8) 
It is highly important to prevent scar-tissue forma- 
tion, whether on or in the brain. The nature of 
the injury, the amount of sepsis, the presence or 
absence of foreign bodies, and the treatment em- 
ployed have much to do with the amount of scar 
formation. 

The routine of treatment is as follows: On ad- 
mission the patient's scalp is shaved, the wound 
thoroughly examined, and two skiagrams taken at 
right angles to each other, and an exhaustive 
neurological examination made. An aperient is 
given and urotropine given. If the brain is exposed 
operation should be done at once and in no case 
should operation be postponed longer than two days. 

The majority of wounds of the scalp should be 
excised and the bone beneath carefully examined. 
If no bone injury is found the wound can usually 
be sutured and primary union almost always 
follows. 

Depressed fracture demands immediate exploration. 
Some cases without injury to the external table may 
have fracture of the internal table, usually suspected 
from the location of wounds or the clinical findings. 
Where the dura is normal in appearance and the brain 
pulsates well it may not be necessary to open the 
dura. When the dura is muddy-looking, and the 
brain does not pulsate it should be opened up by 
means of a crucial incision. The useless brain 
material will usually exude. 

An injury to the dura without foreign body or 
sepsis requires careful trimming of the dura, the 
lost tissue being replaced by a piece of aponeurosis 
and the scalp sutured. Where a foreign body or 
sepsis accompanies the injury its withdrawal is 
attempted and drains usually inserted along the 
track. 

Injury to the blood sinuses can often be closed 
by the application of a small piece of aponeurosis. 
The opening is carefully cleansed and the small 
piece of fascia then quickly applied. 

Lumbar puncture has given relief from persistent 
headache in many cases but, ordinarily, no more 
than 20 ccm. should be withdrawn. J. H. Skiles. 

Cook, F. S.: Bone-Transplantation in Nose De- 
formities. Wis. M. J., 1916, xiv, 427. 

Three cases are reported in detail where bone 
deformities were corrected by bone-transplants. 
The technique is as follows: A curved incision is 
made at the root of the nose and the skin dissected 
free clear to the tip. The periosteum is then incised 
and raised. A piece of rib (ninth) is then inserted. 



with its periosteum still attached, and sutured 
in place. The skin is sutured and the stitches re- 
moved on the fourth or fifth day. The author 
claims very good cosmetic results. J. H. Skiles. 

Mathews, F. S.: Calculi in the Submaxillary 
Gland and Wharton's Duct. Ann. Surg., 

Phila., 1916, Ixiii, 140. 

This author reports six cases of calculi in the 
submaxillary gland and in Wharton's duct, which, 
considering the rarity of the lesion, is an unusually 
large number. Two of his cases presented the usual 
symptoms of pain and swelling at intervals, espe- 
cially at meals, showing the ball-valve action of the 
stone. In others without a preceding history there 
suddenly appeared inflammation and swelling in 
the submaxillary region, accompanied by a high 
fever not unlike mumps. One case had a hard 
swelling under the jaw and a ligneous oedema of 
the tissues of the floor of the mouth. Unless the 
stone is very small it can be readily palpated biman- 
ually even in the presence of considerable swelling. 
All of these cases made a complete recovery after 
the removal of the stone under novocaine anaes- 
thesia through the mouth, either by dilating a 
sinus or incising the duct over the stone. The 
presence of multiple stones must not be overlooked, 
as a second stone frequently exists. Gatewood. 

Kazanjian, V. H.: Treatment of Maxillary Frac- 
tures. Brit. M. J., 1916, i, 266. 

These fractures are usually compound and the 
treatment of the wound is very important, but not 
related especially to the discussion at hand. 

The aim is to maintain a comparative immobility 
of the parts. All the available devices may not 
be sufficient to affect this condition when much bone 
destruction is present. 

The ordinary case is treated by firm bandage 
with wiring of the teeth if such is necessary. The 
care of the mouth is important and antiseptic douch- 
es and applications are recommended. The most 
dreaded complication is haemorrhage. A slight ooz- 
ing may be the beginning of a serious haemorrhage 
and should be carefully followed up. 

J. H. Skiles. 

Cole, P. P., and Bubb, C. H.: Deformities of the 
Jaws Resulting from Operation or Injury. 

Brit. M. J., 1916, i, 268. 

In deformities from operations on the upper jaw 
conditions may be present which require one or 
more of the following procedures: (i) an attempt 
to separate the nasal from the oral cavity; (2) to 
restore the masticating surface; and (3) to restore 
the facial contour. The apparatus is usually made 
of vulcanite and is held in position by aluminum 
pins. 

In simple division of the lower jaw a suitable 
splint may help in coaptation of the ends. When 
part of the mandible has been removed the lateral 
gliding shoes of Aehner are recommended. When 



22 



INTERNATIONAL ABSTRACT OF SURGERY 



one-half of the mandible is removed a modified 
Gunning splint may prove useful. J. H. Skiles. 

Weil, R.: The Treatment of Parotid Tumors by 
Radium. /. Am. M. Ass., 1915, Ixv, 2138. 

Although recent literature contains accounts of 
parotid tumors favorably influenced by radium, 
yet as these tumors are of different types and no 
information has been given as to the microscopic 
structure, definite deductions cannot be drawn as 
to the particular type or types of parotid tumors 
which are suitable for radium treatment. The case 
now reported by Weil has reference to a tumor of 
this kind of seven years' duration, which was 
histologically examined and classed as adenoid 
cystic epithelioma. The general type of the tumor 
was that which Billroth named cylindroma. 

The treatment consisted of the insertion of radium 
into the tumor for six weeks; at the end of this 
period it had disappeared and after an interval of 
almost two years there is no sign of recurrence. 

HoLLis E. Potter. 

Morestin, H.: Repair of Losses of Frontal Sub- 
stance by Means of Cartilaginous Transplants 

(Reparation des partes de substance du frontal a I'aide 
de transplants cartilagineux). Bull, et mem. Soc. de 
chir. de Par., 1916, xlii, 424. 

Morestin reports the operative details of two 
rather extensive breeches in the frontal regions 
repaired by cartilaginous transplants. The tech- 
nique is relatively simple and the results in such 
cases are constantly favorable. The cartilage is 
better taken from the subject himself; but it may be 
borrowed from another operated subject. 

In Morestin's first case there was an osseous loss 
about the size of a five franc piece in the right frontal 
region between the eyebrows and the root of the 
nose. After a series of plastic procedures to restore 
the symmetry of the parts, the breech was finally 
filled with cartilage taken from another patient. 

In the second case where there were also very 
extensive losses and the right eye had been enucle- 
ated, the repairs were effected by material removed 
from the region of the seventh and eighth costal 
cartilages of the patient's right side. In both cases 
excellent results were obtained. 

The work is very delicate as it involves recon- 
struction of the interior part of the upper orbital 
arcade and the frontal region corresponding to the 
root of the nose. W. A. Brennan. 

Landry, L. H.: Intracranial Haemorrhage Due to 
Traumatic Rupture of Arteria Meningea 
Media; Report of Six Operated Cases with One 
Death. South M. J ., 1916, ix, 157. 

It is estimated that 90 per cent of meningeal 
apoplexies prove fatal if unrelieved surgically, 
while of a large series of operated cases 67 per 
cent recovered, a percentage which would have 
been much larger had it been possible to secure 
intervention before the onset of medullary symp- 



toms. All statistics favor operative relief, those of 
Bergmann being the most convincing, 20 successes 
in 22 operations. The great majority of extra- 
dural haemorrhages occur in the lateral aspect of 
the skull, particularly in the temporal region, those 
of slight degree not causing symptoms of compres- 
sion. Ashurst found that a clot between the dura 
and the bone, equaling one-twelfth the capacity 
of the cranium will produce coma and death in a 
few hours. The most common source of the 
bleeding is the torn anterior branch of the middle 
meningeal artery. Occasionally the haemorrhage 
has been sought for on the opposite side, while in 
reality it was on the same side as the existing 
cerebral manifestations at the extremities. The 
author believes that compression of the opposite 
side accounts for the collateral paralysis. 

Usually the patient is so stunned from the 
injury that a degree of unconsciousness is produced, 
from which he recovers only to show evidence of 
cerebral disturbance, headache, possibly vomiting 
and stupor. This free interval was marked in 
four of the author's cases but was absent in the 
first two. In the clinical picture medullary symp- 
toms are invariably present; the blood-pressure is 
high; pulse slow; respiration is labored, later it is 
of the Cheyne-Stokes type; and finally the paralytic 
stage of compression supervenes. 

Compression from any cause must be removed, 
whether from depressed bone, epi- or subdural 
haemorrhage. If given proper attention the most 
terrible injuries of the skull will go on to a good 
recovery. It is safe to say that in any serious 
cranial injury in which unconsciousness has been 
present from the first, subdural bleeding is taking 
place. In localizing the anterior meningeal artery 
the method of Kronlein is the most acceptable. 
At the pterion the artery is found passing forward 
and this point is located by dropping a perpen- 
dicular from the bregma to the middle of the 
zygoma, then drawing a horizontal line back from 
the external angular process; at the junction of 
these two lines is the Sylvian point, the location 
of the pterion. However, all methods of measure- 
ment have lost their importance, as the surgeon of 
today explores through a large aperture and not 
by trephining. Usually the injury to the cranial 
vault is the best guide to the seat of haemorrhage. 

The author advocates immediate exploration and 
decompression in doubtful cases, as such an opera- 
tion adds no more risk to life and often prevents 
a fatal outcome. E. K. Armstrong. 

Gosset, A.: Cranioplasty by Cartilaginous Flap 

(Cranioplastie par volet cartilagineux) . Bidl. el mem. 
Soc. de chir. de Par., 1916, xlii, 444. 

Gosset reports 1 5 cases of cranial osseous breeches 
repaired by cartilaginous flaps. Whereas, Mores- 
tin, who is the originator of this method, usually 
avails himself of several pieces of cartilage in building 
up and closing the breech, Gosset prefers to use one 
single piece. He thinks this gives better results in 



GENERAL SURGERY — SURGERY OF THE HEAD AND NECK 



23 



combating pressure from the brain, and in the pre- 
vention of cerebral hernia. W. A. Brennan. 

Frazier, C. H.: Types of Hydrocephalus; Their 
Differentiation and Treatment. Am. J. Dis. 
Child., 1916, xi, 95. 

The author suggests a new classification, having 
a physiological ' background with direct clinical 
application: 

1. Hydrocephalus obslructivus. 

2. Hydrocephalus nonabsorpius. 

3. Hydrocephalus hypersecretivus. 

4. Hydrocephalus occuUus. 

1. In hydrocephalus obslructivus there is mechan- 
ical obstruction to the natural drainage of the 
cerebrospinal fluid from one or more ventricles 
into the subarachnoid space, where the absorption 
takes place. This obstruction may be due to a 
congenital defect, such as absence of the aqueduct 
of Sylvius or, as is more frequently the case, it 
may be the result of adhesions from a pre-existing 
inflammatory lesion. If the aqueduct of Sylvius 
is lacking or closed by adhesions, there will be a 
dilatation of both the third and the lateral ventricles, 
while a closure of the foramen of Munro would 
cause merely an enlargement of the lateral ventricle 
on the affected side. If, as is often true in cases of 
high-grade but evenly-distributed hydrocephalus, 
the passage of the fluid through the foramina of 
Magendie and Luschka is blocked, there will be a 
general dilatation in which all the ventricles par- 
ticipate. 

2 . In hydrocephalus nonabsorpius absorption is de- 
layed or defective, as has been proved by the 
phenolsulphonephthalein test. Whether the re- 
stricted absorption is to be attributed to (i) the 
cutting off of part of the subarachnoid space by 
adhesions, (2) a toxic substance in the fluid which 
prevents its absorption by the venous channels, or 
(3) whether it is due to an abnormal condition of 
the agents which transport the fluid to the venous 
circulation, is still a matter of conjecture. 

3. By a process of elimination and by a careful 
consideration of the normal physiology of the cere- 
brospinal fluid and of the possible changes under 
abnormal conditions, the third type, with apparent 
excessive accumulation of fluid, has been attrib- 
uted to hypersecretion — hydrocephalus hypersecre- 
tivus. Since it has been conclusively proved by 
morphologic and histologic studies of the choroid 
plexus, by chemical analyses of the fluid, by a 
study of the effect of choroid extract on the secre- 
tion of cerebrospinal fluid, that the cerebrospinal 
fluid is the secretory product of the choroid gland, 
it would seem logical to suppose that a pathologic 
condition of the gland itself or a toxic substance in 
the fluid coming in contact with the plexus might 
bring about a hyperactivity of its cells. 

4. The author includes in the varieties of hydro- 
cephalus a fourth type, for which the term hydro- 
cephulus occultus has been chosen, which though 
paradoxical, is otherwise appropriate. The con- 



dition thus designated occurs usually in children, 
though occasionally in adults, and is characterized 
by excess of fluid in the ventricles, basal cysternae, 
and sometimes throughout the subarachnoid space, 
without there necessarily being any increase in the 
cranial dimensions. Symptomatically, this con- 
dition may be more closely allied to tumors, but, 
from the point of view of treatment, it properly 
belongs to the problems of hydrocephalus in that 
the essential feature is an excessive accumulation 
of cerebrospinal fluid in the subarachnoid space. 

The clinical tests may be summarized as follows: 

First examinations: 

1. Lumbar puncture. 

2. Withdrawal of i ccm. of cerebrospinal fluid. 

3. Attach 2 ccm. record syringe filled with i 
ccm. neutral solution of dye. 

4. Withdraw piston until syringe is full. 

5. Inject solution slowly into lumbar subarach- 
noid space. 

6. Withdraw needle. 

7. Test urine for phenolsulphonephthalein every 
five minutes until dye is detected. 

8. Estimate the total amount of dye excreted in 
the first 2-hour specimen of urine. 

Second examination on the following day, or 
after dye is no longer found in the urine: 

1. Puncture of the lateral ventricle. 

2. Inject I ccm. netural phenolsulphonephthalein 
solution. 

3. Lumbar puncture; examine for dye every 
five minutes until dye appears. 

4. Test five-minute specimens of urine. 

5. Estimate total amount of dye excreted in 
first two-hour specimen. 

6. In calculations, the amount of dye lost by 
lumbar puncture must be taken into consideration. 

The simplest and most effective method of deal- 
ing with hydrocephalus obslructivus is puncture of 
the corpus callosum, the Balkenstich of Anton 
and Bramann. 

In the non-absorptive type, greater technical 
difficulties are encountered. With some reserva- 
tion, because his technique is in the developmental 
stage, the author recommends the establishment of 
a drainage tract into the pleural cavity. When 
the lesion is due to hypersecretion, he resorts to 
thyroid feeding. Edward L. Cornell. 

Remsen, CM.: The Relation of the Pathological 
Bases of Hydrocephalus to Its Surgical Allevia- 
tion. Interst. M. J., 1916, xxiii, 89. 

The condition leading to the development of 
hydrocephalus may be primary, as in the congenital 
type, or secondary to obstructions of the foramina 
of exit (meningitic adhesions) or of the veins of 
exit, as in brain tumor. 

Trauma, lues, tuberculosis, septic meningitis, 
brain tumor, and chronic alcoholism may be asso- 
ciated with it, while tubercular meningitis may lead 
to fatal hydrocephalus. 

The author outlines the anatomy and physiology 



24 



INTERNATIONAL ABSTRACT OF SURGERY 



of the ventricular system, and discusses the sources 
of origin of the cerebrospinal fluid. By means of 
experimental blocking off of the ventricular cavities 
and stimulation of the choroid plexus, the latter 
have been shown to be the chief origin of the fluid. 
Likewise, other experiments have shown the egress 
of the fluid to be chiefly by means of absorption into 
the arachnoid villi and venous sinuses. Hence, an 
increase in the cerebrospinal fluid may be due to (i) 
an overproduction by the choroid plexus; (2) a 
disturbance of the principal absorptive system — 
the arachnoid villi and sinuses; or (3) to a mechani- 
cal obstruction in the course of its flow from the 
plexus, through the ventricles and subarachnoid 
space, to the sinuses. 

That certain types of this condition (choroidor- 
rhoea) may be of toxic origin seems probable from 
the effect of the injection of certain drugs or ex- 
tracts, since brain, plexus, or pituitary, and also 
muscarine have a stimulating, thyroid a depressing, 
effect upon the secretion. As regards pathological 
conditions producing symptoms of hydrocephalus, 
the author points out that large posterior fossa 
tumors are sometimes without signs of increased 
fluid tension, and that the important sign of choked 
disk may not be due directly to the tumor itself but 
to the hydrocephalus, causing infiltration of cere- 
brospinal fluid along the optic nerve sheaths and 
compression of the venous return from the retina. 
In essential hydrocephalus with no pathological 
obstruction, a vicious circle resulting from excess 
accumulation of fluid in the cisterna magna pressing 
on the veins of Galen, which causes increased intra- 
sinus pressure and depresses absorptive action, is 
responsible. Forcing upward of the midbrain and 
plugging of the tentorial opening may also be a 
factor. 

The practical results of obstructive conditions 
being a cutting off of the secretory from the ab- 
sorptive systems, it is unlikely that thyroid extract 
or other therapeutic substances will be of benefit, 
and evidently a communication between the 
systems must be established. The author mentions 
the various operations devised for this purpose, 
and recommends the method of von Bramann as 
the simplest. In this a ventriculostomy is per- 
formed by the passage of a blunt cannula by way of 
the longitudinal fissure and puncture of the dis- 
tended lateral ventricle. The continual escape of 
fluid into the subarachnoid space equalizes the 
pressure and conditions approach normal. This 
operation is indicated both in hydrocephalus of the 
obstructive type and in essential choroidorrhoea in 
infancy, before cerebral destruction has occurred. 
The technique of the operation is outlined. Failures 
may be due to closure of the ventriculostomy 
opening. Horace Binney. 

Jacob, F. M.: Glioma of the Cerebellum with 
Metastases. J. Med. Research, 1916, xxxiv, 95. 

Jacob reports the case of a young adult giving a 
typical history of brain tumor extending over a 



period of two years. The autopsy showed a large 
glioma of the cerebellum which had extended into 
and obliterated the fourth ventricle and occupied 
most of the central white matter of the cerebellum. 
Smaller masses of a similar character were dis- 
tributed upon the ependyma of the lateral ventricle, 
the central canal of the spinal cord, and the leptome- 
ninges. All of these masses were very cellular, 
unencapsulated, infiltrating and, to all microscopical 
appearance, malignant in character. Gland-like 
and rosette structures were noted in many parts 
of the tumors. The masses in the ventricle were 
discrete and had a nodular papillomatous structure, 
but the pia mater of the cerebrum, cerebellum, and 
cord contained a patchy growth of gliomatous 
tissue extending over a considerable area, involv- 
ing much of the surface of the brain and cord. He 
found no masses in any organs outside the cranial 
and spinal cavities. 

From his study the author draws the following 
conclusions: 

1. Although gliomata of the brain do not invade 
blood and lymph channels or form metastases in 
distant organs, they do form metastases in the 
brain and cord by means of cerebrospinal fluid. 
The reason for this, he believes, may be found in 
the fact that glia cells are highly specialized and 
cannot grow when removed from their natural 
surroundings. 

2. Even though gliomata of the brain do not 
metastasize to other organs, many of them, the 
author thinks, should be considered histologically 
malignant or at least locally malignant on account 
of their power of infiltration, rapid rate of growth, 
and the embryonal character of the cells. 

George E. Beilby. 

Grey, E. G.: Studies on the Localization of Cere- 
bellar Tumors. Ann. Surg., Phila., 1916, Ixiii, 129. 

Notwithstanding the comprehensive literature 
which pertains to diseases of the posterior cranial 
fossa, the significance of the position of the head and 
of suboccipital discomfort still remains uncertain. 
The author has carefully analyzed the symptoms in 
60 certified cases of cerebellar and extracerebeUar 
tumors from Cushing's neurological service in an 
attempt to determine a consistent relation between 
the position of the head and the location of the 
tumor. About 40 per cent of the cases with cere- 
bellar tumor showed some change in the position 
of the head, while only 7 per cent of the cases with 
tumors anterior to the cerebellum showed any 
unusual attitude, and in each of the latter cases the 
change was slight. The tilting of the head or its 
rotation in patients with symptoms pointing toward 
an intracranial tumor is very suggestive of a sub- 
tentorial new-growth. The attitude has no par- 
ticular significance in localizing the lesion in one 
side or the other of the cranial fossa. 

Backward retraction of the head occurred in 
8 out of the 60 cases and typical opisthotonos attacks 
appeared in 2 of these cases. As this condition 



GENERAL SURGERY — SURGERY OF THE HEAD AND NECK 



25 



was not noted in any case of tumor anterior to the 
cerebellum, backward retraction of the head may be 
said to be characteristic of new-growths situated 
below the tentorium. 

Atrophy and osteoporosis of the subjacent bone 
from tumor extension may occasion occipital ten- 
derness in some cases, but comparisons of the clinical 
and operative findings in this series showed no 
consistent relations existing between the two. 

Headache or pain is the most frequent of the 
suboccipital discomforts, and was present in some 
form in 75 per cent of the cases examined. While 
occipital discomforts occurred to some degree in 
lili per cent of 43 cases with tumors anterior to the 
cerebellum, as a rule, they were much less intense 
than in the cases with subtentorial new-growths. 
Taking the series as a whole, no consistent relation 
has been found between the part of the cranial 
fossa occupied by the tumor and the site of the dis- 
comfort. When unilateral discomfort is present, 
however, it may be slightly suggestive of the side of 
the new-growth. 

Since suboccipital discomforts were present more 
than twice as often in patients with posterior cranial 
fossa lesions as in those with tumors situated else- 
where in the brain, the author concludes that they 
must be ranked with asynergy as the most important 
indications in the localization of intracranial new- 
growths. Posture of the head, while of no value in 
localization of the side of the lesion, must also be 
considered as a sign of considerable value in localiz- 
ing subtentorial tumors. Gatewood. 

NECK 

Winslow, R. : Tumors of the Carotid Body. Tr. 

Am. Surg. Ass., Washington, 1916, May. 

The author's paper is based upon the report of 
two cases of this character operated on by A. M. 
Shipley and himself, respectively, and a somewhat 
comprehensive review of the subject is given, with 
a brief summary of the cases that have been reported 
in the past three years. 

Shipley's case was a girl, 16 years old, with a 
rapidly growing tumor, the size of a hen's egg, on 
the right side of the neck. This had only been no- 
ticed for two months previous to operation. There 
were no symptoms except the presence of the lump. 
The tumor, which was situated in the upper carotid 
triangle, was movable laterally but not vertically. 
At operation the common carotid artery was found 
to run through the mass and was ligated above and 
below and excised. At once the heart action became 
tumultuous and ran wild for five days, when it 
gradually returned to normal. The patient was 
well five years subsequently, without recurrence. 

Winslow's case was a man, 24 years of age, who 
had noticed a lump on the left side of his neck for 
eight years. The lump gave little or no distress but 
grew slowly to the size of a hen's egg. The tumor 
was single, smooth, somewhat movable but also 
fixed, not painful but somewhat tender on deep pres- 



sure. It was situated in the upper carotid triangle 
on the left side, and was suspected to be a "carotid 
tumor." When it was exposed by incision it could 
not be removed until the common and internal 
carotid arteries were ligated and excised. No 
cerebral or cardiac disturbance followed the ligation 
of these vessels, and with the exception of a laryn- 
geal paralysis no complications arose. He made a 
good recovery and was free from recurrence 18 
months later. The tumor was an endothelioma. 

In addition to these cases, Winslow reports an 
unpublished case of bilateral carotid tumor operated 
on by William Perrin Nicolson, Atlanta, Ga. 

A woman, 43 years old, had a very large mass on 
the left side of the neck, which had only been noticed 
for nine months. On the right side was a small 
movable lump that was of only two months' 
duration. Pressure symptoms were causing dis- 
tress and the patient clamored for relief. Operation 
was very difl&cult, but the growth on the left side was 
finally isolated and removed after ligation of the 
common and internal carotid arteries which tunneled 
the mass. A very severe physiological storm set 
in immediately with pulse-rate 1 50, suffusion of the 
left side of the face and the left eye, aphonia, paralysis 
of the muscles of deglutition, and bronchorrhcea. 
These symptoms gradually improved and in three 
weeks an attempt was made to remove the gland on 
the opposite side. This was accomplished by dis- 
secting the tumor from the vessels without ligating 
any of them. The patient recovered from the two 
operations but died of recurrence in four months. 

Tumors of the carotid ganglion are being reported 
in ever increasing numbers but are stUl surgical 
rarities. They occur with equal frequency in males 
and females and though observed most often from 
20 to 60 years of age are also seen at other periods 
of life. 

A single, slow growing, firm, smooth, discrete^ 
usually painless, oval lump, more or less fixed^ 
situated in the upper carotid triangle, opposite 
the thyroid cartilage and anterior to or under the 
sternomastoid muscle, should always cause one to 
suspect a neoplasm of the carotid body. 

As these tumors are either potentially or actually 
malignant the question of treatment is an important 
matter. The common carotid artery often tunnels 
the growth, making its removal impossible without 
ligating and excising the artery with the mass. The 
pneumogastric nerve also is frequently in such 
close proximity to the tumor that it is injured, 
with serious results. In consequence of these, as 
well as of other facts, operations for the removal of 
carotid tumors are fraught with danger and the 
mortality is high. In some cases the growth can be 
dissected from the vessels without injuring them, but 
the recurrences are very high. 

In 34 cases in which the main vessels were ligated 
there were 11 deaths, but only 2 or 3 recurrences 
were noted in those who survived; while in 25 cases 
in which the tumor was dissected from the arteries 
only one died, but recurrence occurred in 8 cases. 



26 



INTERNATIONAL ABSTRACT OF SURGERY 



In the opinion of the author all such cases should 
be removed, even if it involves the ligation and ex- 
cision of the carotids, and no attempt should be 
made to dissect the tumor free from the vessels un- 
less it is only loosely attached to them. 

Leriche: Resection in the Case of Projectile 
Wounds of the Neck (Resection dans les plaies 
du conde par projectiles de guerre). Bull, et mem. 
Soc. de chir. de Par., 1916, xlii, 416. 

Leriche reports the details in the case of four 
resections of the neck which he has performed owing 
to injury of the articulation. Two of these were 
done within a few days after the injury and the 
other two were done considerably later. Excellent 
results were obtained in the late cases, but in the 
other cases there were defects of lateral movement. 
OUier's technique was followed. 

In submitting Leriche's report, Quenu considers 
that there are three categories of neck resections: 
(i) primitive, practiced immediately or in the first 
days after injury and before there is any infection; 
(2) early secondary, made within a few weeks of 
injury; and (3) late secondary, when the acute stage 
is passed and when only a fistulous trajectory is 
present or even cicatrization is effected. Quenu 
thinks that whenever the articulation is involved 
primitive resection is called for. He reports some 
cases under each category observed by him with 
particulars of treatment and results obtained. 

W. A. Brennan. 

Evans, J. S., Middleton, W. S., and Smith, A. J.: 
Tonsillar Endamoebiasis and Thyroid Dis- 
turbances. Am. J. M. Sc, 1916, cli, 210. 

The authors discuss the etiological role played 
by an endamoebic infection of the tonsils in endemic 
goiter, and give a summary of the present-day 
conception of the part that is played by chronic 
infections in the causation of goiter, quoting the 
work of McCarrison on endemic goiter in India, 
his opinion being that one of the etiological factors 
is infection of the intestines from drinking water. 
He showed how the boiling or filtering of water 
rendered it innocuous, whereas the feeding of 
unboiled water to non-goitrous patients was fol- 
lowed by thyroid enlargement. 

Farrant is quoted as advancing the first definite 
evidence of a specific bacterial agent, proposing 
the theory and evidence of a mutant colon bacillus 
in the intestinal tract as an important factor in 
goiter production through the agency of its toxins. 
He also quotes Halstead and Billings' views on the 
part that infections play in the causation of thyroid 
enlargement. 

The authors do not hold that infection is the only 
factor in goiter, but put forth the idea that it is one 
of the numerous agencies that may influence the 
development of the disease. 

A statistical study was made at the Medical 
Clinic of the University of Wisconsin, with refer- 
ence to coexistent infections of the nose and throat 
in their association with goiter. Of the 1,328 men 



examined, 27.2 per cent had thyroid involvement; 
of 362 goitrous individuals examined, 90 per cent 
had nasal and tonsillar infections. In tonsils of 
34 cases examined microscopically, 97 per cent were 
found to have endamoeba gingivalis (Gros) in the 
tonsillar crypts. Of 16 individuals of this group 
who after treatment by emetin hydrochloride were 
re-examined, 81 per cent were shown to no longer 
have the organism in the crypta contents. In 
23 individuals, to whom emetin was administered, a 
reduction in the bulk of the goiter was appre- 
ciable in 18, and in 7 dysthyroid cases included in 
this group of the cured cases, 6 were benefited in 
degrees varying from slight amelioration to appar- 
ent cure. 

Inability to demonstrate endamoebae in the 
thyroid gland renders improbable any direct causal 
relation of the amoebic infection of the tonsil per se 
upon the development of thyroid disturbances. 
The improvement, morphologically and symptomat- 
ically, in the treated cases leaves little doubt, after 
ruling out a vasomotor influence from the emetin 
employed, as to an indirect relationship. A 
symbiosis of endamoebae with appropriate bacteria, 
leading to the elaboration and absorption into the 
thyroid of selective thyrotoxic poisons via the 
blood stream is at least conceivable in explanation 
of such relation. 

In no sense do the authors care to be understood 
as advancing hereby an exclusive explanation for 
all goiters. Other types and other locations of 
infections capable of producing thyrotoxic toxins, 
perhaps, too, toxic substances having a similar 
influence but derived from metabolic or alimentary 
fault, or even entering the body from without, are 
all of possible influence. Nor is the influence of 
sympathetic stimulation, however accomplished, 
to be overlooked. The authors are unable to find, 
however, in any of these lines of thought, any satis- 
factory explanation of the known occurrence of 
belts of endemic goiter along certain well-defined 
glacial drifts. Harry G. Sloan, 

Koch, W. F.: The Physiology of the Parathyroid 
Glands. /. Lab. &* Clin. Med., 1916, i, 299. 

After a consideration of ductless glands in general 
and the parathyroids in particular, Koch endeavors 
to elucidate the obscure mechanism of the activity 
of these glands. 

The behavior of the parathyroidectomized dog 
may, he says, coincide with either of two distinct 
types of symptoms, or with a mixture of these types, 
in which either may predominate. In one type the 
dominant feature is over-excitability; in the other 
under-excitability. In the former tonic convulsions 
are characteristic; in the latter we observe a peculiar 
muscular flaccidity and a general depression of 
the nervous system. In either case a pathological 
condition develops within a few days after removal 
of the glands and proves fatal within two to ten 
days. 

Up to the present only one fact which contributes 



GENERAL SURGERY — SURGERY OF THE CHEST 



27 



to the explanation of this pathological process has 
been advanced; it is the discovery by MacCallum 
that the urines of parathyroidectomized animals 
contain excessive quantities of calcium; and that 
when calcium salts are injected intravenously into 
such animals, the tetany is immediately controlled. 
It was shown by Beebe and Berkeley that injections 
of other salts have a similar though not so marked 
an effect. 

Koch recently found that when the tetany had 
become uncontrollable by injections of aqueous 
salt solutions, the kidneys had become so patholog- 
ical as to be unable to functionate normally. Since 
one of the effects of such intravenous injections is 
diuretic, it may be assumed that one of the beneficial 
effects of the aqueous calcium injections depends 
upon increasing the work of the kidneys and thus the 
detoxication of the blood. If on the other hand the 
value of calcium depends upon the increasing or 
maintaining of a certain reaction of the blood, the 
acid radicals are here the important factors. They 
present two possible modes of activity, the simple 
neutralization of basic substances excessively elab- 
orated within the body or the destruction of such 
substances as are capable of producing the tetany. 

There are then several indications that the tetany 
of parathyroid insufiiciency is due to an intoxica- 
tion; namely, that it is subdued by increased diuresis, 
and by the neutralization of toxic basicity, or the 
destruction of a toxin by acidity. That the origin 
of the hypothetical toxic substance is the body it- 
self, that it is useful and not toxic in the presence of 
the parathyroid glands, and that it is filtered through 
the glomerulus of the kidney, point to a substance 
hormone-like in nature and therefore very unstable 
chemically. 

In the effort to ascertain the presence and identity 
of such a substance the urines were collected 
separately from 47 parathyroidectomized dogs. 
Especially designed cages were used to avoid faecal 
contamination. The urines were filtered and 
evaporated to a syrup by an electric fan at a tem- 



perature not above 20° C. The residues were dis- 
solved in alcohol, filtered and evaporated, and this 
process repeated until the last evaporate dissolved 
readily in alcohol. The lipoids present were ex- 
tracted with ether and the residue taken up in 
water. This solution was cautiously precipitated 
with picrolonic acid. Several insoluable picrolo- 
nates were thus obtained, and by recrystallization 
from water and alcohol were purified. These sub- 
stances were tested for physiological activity. Two 
of them were found to modify the blood-pressure 
when injected intravenously into anaesthetized dogs. 
When injected intraperitoneally into non-anaes- 
thetized animals they exhibited very marked toxic 
effects. Because of the agreement in chemical and 
physiological properties he considered the substances 
identified as methylcyanamide and trimethylmela- 
mine. 

Physiological tests were made with methyl- 
cyanamide isolated from the urines and the synthetic 
methylcyanamide; when injected intraperitoneally 
in non-anaesthetized dogs they were found to have 
similar effects. In small doses they produced ex- 
treme vasodilatation, observed in the reddening of 
the sclera and swelling and reddening of the tongue. 
Larger doses caused paralysis and convulsions. 
Still larger doses caused an extremely rapid death. 

The author concludes as follows: The similarity 
in the behavior of the parathyroidectomized dogs, 
to that of the non-anaesthetized animals treated 
with the substance isolated from the urine, is further 
indication that this substance is responsible for the 
symptom-complex of parathyroid insufficiency. 
The data therefore justify the following conclusions: 

1. Somewhere in the body methylcyanamide is 
generated. 

2. This substance has a physiological value in 
normal animals. 

3. After parathyroid extirpation the substance 
accumulates to toxic quantities, and is responsible 
for the death of these animals. 

Albert Ehrenfrted. 



SURGERY OF THE CHEST 



CHEST WALL AND BREAST 

Perreau, H. : Penetrating Wounds of the Chest in 
Warfare. Med. Press 6* Circ, 1916, ci, 100. 

A penetrating wound of the chest requires imme- 
diate immobilization of the chest. The diagnosis 
should therefore be made as soon as possible and 
doubtful cases should be treated by immobilization 
also, as it can do them no harm and may even 
expedite healing. The early diagnosis is greatly 
assisted by the roentgen ray. 

The immediate immobilization of the chest is 
necessary to avoid severe complications. Among 
these complications may be mentioned: (i) Embolism 
which may be caused by any sudden movement, 



even after a considerable lapse of time, and which 
may prove rapidly fatal. (2) Pleural effusion 
is very common and may change to a purulent 
fluid. (3) Subcutaneous emphysema may occur, 
either local or more or less general. (4) Broncho- 
pneumonia and haemorrhage are rare complications. 
In order to lessen the liability to these complica- 
tions, immediate, absolute, and prolonged im- 
mobilization is necessary. 

The conclusions reached by the author are as 
follows: 

1. An early diagnosis should be made by the aid 
of radioscopy whenever possible. 

2. Immediate, absolute, prolonged immobiliza- 
tion should be ordered. 



28 



INTERNATIONAL ABSTRACT OF SURGERY 



3. The patients should be kept on a water diet 
for the first two or three days, not allowing them 
to raise the head to drink. 

4. Such patients should not be transferred until 
after a fortnight's immobility. 

5. During the first four or five days a daily dose 
of 10 ccm. of camphorated oil should be given. 

6. Except when absolutely necessary no attempt 
should be made to remove intrathoracic projectiles. 

7. Prompt, wide opening should be resorted to, 
to give issue to early copious purulent effusions. 

J. H. Skiles. 

Boothby, W. M.: Gunshot Wounds of the Thorax. 

Boston M. &° S. J., clxxiv, 1916, 378. 

The author discusses his observations on 21 cases 
of thoracic injuries out of a total of 441 wounds of 
all kinds treated in the Harvard Unit. The cases 
observed fortunately included examples of most of 
the important thoracic lesions which reach hospital 
care. 

Haemoptysis was present in nearly all of the cases. 
In some it was very slight, lasting for a short time; 
in others it was present for many days. It was 
more apt to be present when the lesion occurred 
from the larger and irregularly shaped missiles. 

Haemothorax is a complication which arises from 
injury to blood-vessels belonging to the general 
rather than to the pulmonary circulation, such as 
the intercostals, the internal mammary arteries 
and veins, and the azygos veins. These vessels 
are not surrounded by muscular tissue, hence the 
tendency to haemorrhage from them. An additional 
cause of haemorrhage is due to the fact that the 
blood shows no greater tendency to clot when it is 
in contact with the endothelial lining of the pleura 
than it does when in contact with the endothelium 
of the blood-vessels. Toeuniessen found that at 
first the fluid was dark red, with a cell count essen- 
tially similar to that of blood, but with fewer red 
cells and a higher percentage of eosinophiles. The 
fluid had no tendency to clot in the pleural cavity 
or when withdrawn. When the vessels had finally 
stopped bleeding the fluid became brighter red, 
with a decrease in the number of red cells, though 
the white cells remained the same. The percentage 
of eosinophiles gradually increased, as much as 
70 per cent. The fluid while showing no tendency 
to clot in the pleural cavity, clotted when with- 
drawn. During the stage of absorption the fluid 
became less hsemorrhagic and at times almost 
entirely serous. At this stage it again lost its 
clotting power when withdrawn from the pleural 
cavity. 

Penzoldt states that at first the blood is defibri- 
nated, and later as pleuritic irritation develops, 
an increase in leucocytes occurs with the develop- 
ment of a new blood-clotting substance from the 
pleural endolethelium. When the fluid remains 
long enough in the pleural cavity this clot-pro- 
ducing substance gradually disappears with the 
pleural irritation. The presence of the eosinophiles 



is due to some local cause as they are not present 
in increased number in the circulating blood. 

Sauerbruch has pointed out that bleeding from 
lung tissue, or the vessel of the pulmonary circula- 
tion, is of short duration. The lung tissue itself 
seems to possess a haemostatic action; the early 
clotting of blood is also favored by the low pres- 
sure existing in the pulmonary system of vessels; 
and, lastly, the vessels of the pulmonary circulation 
are surrounded by a loose tissue which, on injury, 
contracts down on the bleeding vessel. 

The most important principle in the treatment 
of haemorrhage is absolute rest which favors a low 
blood-pressure and clotting. Since it has been 
shown that late bleeding is apt to occur in from 
eight to fourteen days after the injury it is better 
to allow a period of rest of two weeks to elapse 
before extended transportation is undertaken. 

Out of 84 post-mortems observed by Bradford 
and Elliott at Boulogne, in which death resulted 
from chest-wounds, 69 had effusion of blood in the 
pleural cavity; 23 died of complications like puru- 
lent bronchitis, paraplegia, or abdominal lesions; 
46 died from haemothorax, in 38 of which infection 
was present. Death from haemorrhage resulted 
only in one case. 

In one group of 168 cases of haemothorax treated 
clinically 114 were sterile and 48 had such large 
effusions that it was necessary to aspirate. Twenty- 
eight infected effusions survived after resection of 
rib. Twenty deaths were due to infection. 

In a second group of 160 cases, 68 remained sterile, 
and of these 41 required aspiration, 53 cases were 
infected and survived resection of rib. Out of 21 
deaths 16 were infected. There was one death from 
simple haemothorax. 

The foregoing statistics show the dangers of 
infection in haemothorax. The authors insist on a 
rest of three days after the receipt of the wound. 
The patient is then taken as rapidly and com- 
fortably as possible to a place where surgical work 
may be undertaken with safety. 

Aspiration to remove part of the fluid and to 
thereby hasten absorption should not be delayed 
unduly since the presence of haematoma favors the 
formation of dense pleuritic adhesions with time. 
The military surgeon is often prevented from 
operating with safety in field practice, but when- 
ever he commands his environments for aseptic 
work the rule of aspirating early rather than late 
should be practiced. The presence of increased 
temperature which prompts aspiration is not always 
the result of sepsis. The rise may be due to absorp- 
tion of fibrin, and it may be further aggravated by 
respiratory embarrassment and mental worry. 
The rule is to aspirate in all cases of irregular tem- 
perature and to practice thoracotomy whenever 
pus is found. 

When aspiration becomes necessary the amount 
of fluid to be withdrawn is a debated point. Sauer- 
bruch believes that this should not exceed 20 to 
30 ccm. If too much fluid is removed the intra- 



GENERAL SURGERY — SURGERY OF THE CHEST 



29 



pleural pressure will be lowered and there will be 
a tendency to recurrent haemorrhage. In order 
to avoid this danger it is better to aspirate with a 
simple aspirating needle to which is connected a 
rubber tube 30 cm. long, the whole of which is 
filled with sterile water and the distal end immersed 
in a basin of sterile water. This method produces 
a suction equivalent to the difference in the level 
between the surface of the water in the basin and 
the level of the needle which may be varied up to 
30 cm. This amount of suction can be practiced 
with safety. The method is less risky than the use 
of an aspirating bottle and pump with which a 
negative pressure of considerable amount may be 
produced by the pump. 

In pneumohaemothorax air present above the 
level of the liquid generally disappears rapidly 
unless there is a permanent communication with a 
bronchus. The latter adds to the danger of sepsis, 
and when sepsis ensues thoracotomy is in order. 

Cardiac injuries are treated by absolute rest and 
morphia given in sufficient quantities to keep the 
patient drowsy. Immediate operation is rarely 
possible under field conditions at the front. The 
service that preceded the Harvard Unit removed a 
bullet by operation that lay free in the pericardial 
cavity. The patient recovered in spite of an em- 
pyema following the operation. 

All cases with a patent opening in the pleura 
become infected. The frequency of infection 
depends largely upon the character of the missile, 
and the condition of the patient's skin and clothes. 
Infections are more frequent in proportion to the 
distance from the front. One observer saw empyema 
in 3 out of 28 cases; another 2 out of 43 cases. 
Tuffier saw infections develop most frequently after 
shell wounds and when a foreign body was lodged. 

Some observers point to the resistance of the 
pleura to infection as shown in repeated instances 
of infected external wounds leading to the pleural 
cavity in which the pleural wound closed, thus 
warding off infection. It is generally agreed that 
the pleural membrane and the extrapleural fibrous 
tissue are very resistant to the passage of infection 
from the extrapleural to the intrapleural surface. 
Nevertheless care should always be taken not to 
open the pleura in cases of large septic haematomata 
that develop extrapleurally and which are not 
connected with the pleural cavity. 

When thoracotomy becomes necessary it should 
be done at the most dependent part of the cavity 
and the opening should be large enough to admit 
the hand for thorough exploration and to remove 
foreign matter. Such a procedure wards off em- 
pyema and enables the operator to remove lodged 
missiles embedded in lung tissue near the surface. 

The author concludes his article with the fol- 
lowing summary: 

I. Intrathoracic haemorrhage is most likely to 
cease when the patient is absolutely at rest; there- 
fore he should be kept in bed (under morphia if 
necessary) at the first available station. 



2. Symptoms rapidly developing, suggesting 
pneumonia with marked dyspnoea, are probably 
due to the production of a large haemothorax or a 
pneumothorax. Such cases should be aspirated 
and sufficient fluid withdrawn to relieve the dys- 
pnoea. Care should be taken not to produce a 
negative pressure within the thorax by the use 
of an aspirating bottle. A simple needle with 
rubber tube 30 cm. long, filled with sterile water, 
and the open end immersed in a basin of sterile 
water, will produce as great a suction as it is safe 
to use. With such an apparatus as much fluid can 
be withdrawn as will run out of its own accord. 

3. After three days the danger of infection 
exceeds that of haemorrhage. Therefore, if the 
patient is not in a place equipped for diagnosing 
and operating for empyema, he should be removed 
to the nearest hospital so equipped, and kept there 
for at least two weeks. 

4. Whenever the patient presents an irregular 
elevation of temperature, exploratory aspiration 
with a small hypodermic syringe, armed with a long 
needle of large bore, should be performed. 

5. Whenever the pleural fluid is found infected, 
a long thoracotomy opening should be made and 
free drainage instituted. 

6. If the patient is in a dangerous condition, 
prolonged search for the presence of a foreign 
body should be deferred. However, all foreign 
matter should be removed as soon as possible in 
order to hasten the final closing of the wound. 

L. A. LaGarde. 

Herrick, J. F.: Enlarged Thymus in Infancy. 

Surg.,Gyncc. b'Obst., 1916, xxii, 333. 

The symptoms of enlarged thymus may manifest 
themselves within a week after birth. The symp- 
toms are very similar to those of a foreign body in 
the air passages. The respiratory difficulty may 
manifest itself in all possible grades, from a mild 
stridor to very severe dyspnoea with fatal termina- 
tion. The symptoms may be the result of pressure 
on the trachea, on the large vessels, or on the right 
auricle as appeared in one of the following cases. 
The diagnosis is aided by more gradual onset, in- 
creasing trouble, absence of X-ray evidence of 
foreign body, with X-ray shadow of enlarged gland, 
broadened sternal dullness, negative laryngoscopic 
findings, and failure of intubation to relieve. The 
child is usually well nourished but the complexion 
is usually pale and pasty. There is no disturbance 
of pulse or temperature. The treatment may be 
surgical or X-ray. The former is at times followed 
by death. The latter is safe and effective. 

Six cases are reported: Case i, aged i year, 
died under anaesthesia, in an effort to locate a foreign 
body. Autopsy revealed a very large thymus over- 
lying the right auricle; no foreign body present. 
Case 2, aged 3 years 7 months; symptoms present 
since the child was 3 years of age. The child died 
suddenly without treatment. Case 3, aged 6 
months; symptoms began when child was ten weeks 



30 



INTERNATIONAL ABSTRACT OF SURGERY 



old. Symptomatic treatment only was given. 
The child was living but in a serious condition 
when lo months of age. Case 4, aged 4 weeks; 
symptoms present since two weeks of age, attacks 
very severe. Treatment with X-ray was followed 
by recovery. Case 5, aged 8 months; symptoms 
present since first week after birth. Treatment by 
X-ray; recovery. Case 6, aged 2 months; symp- 
toms present since first week of life. Treatment' 
by X-ray; recovery. 

TRACHEA AND LUNGS 

Villeon, P. de la: The Surgical Extraction of Intra- 
pultnonary Projectiles, Superficial and Deep, 
Under the Screen, by Simple, Rapid, and 
Certain Means (L'extraction operatoire des pro- 
jectiles intrapulmonaires, superficiels et profonds, 
sous I'ecran, par un precede simple, rapide et sur). 
Bull. Acad, de mid., Par., 1916, Ixxv, 275. 

Thoracopneumotomy for the extraction of intra- 
pulmonary projectiles has been practiced by the 
author with uniform success. 

He also uses a method much simpler and more 
rapid, which was carried out successfully in 29 cases. 
.The principles of this new procedure are based 
on the method for using the radioscopic screen 
for the extraction of intrapulmonary projectiles, 
which was originated by Mauclaire. Villeon's 
technique is different from that of Mauclaire in that 
it allows of the extraction of deep as well as super- 
ficial projectiles. 

The projectile being located by X-ray, the 
anaethetized patient is placed under the screen, in 
a dorsal or abdominal position, according to the 
nearness of the projectile to the anterior or posterior 
surface of the lung. The projectile makes a shadow 
on a point of the thoracic parieties. Two or three 
finger-breadths away, in the intercostal space, by 
means of a tenotome or a fine blade, a narrow 
5-mm. buttonhole incision is made in the skin. 
Through this incision is introduced a closed forceps 
(long Pean, long Kocher) or an old style forceps for 
the extraction of bullets. This forceps passes with 
difficulty into the narrow buttonhole incision, and 
following a line oblique to the normal of projection, 
leads directly to the projectile. It turns aside 
before it the intercostal fibers, grazes the upper 
border of the inferior rib (to avoid wounding the 
vessels), and always closed, goes through the 
parietal pleura, then the visceral pleura; it then 
enters the parenchyma where by a gentle handling 
it is pushed up to the projectile and touches it. 



At this moment, the X-ray operator intervenes 
for the second time, to ascertain whether the 
forceps is in the right place, if not, to correct the 
direction. The forceps touches the projectile and 
mobilizes it. The forceps then opens gently, catches 
the fragment and extracts it as the opening through 
which the forceps enters the skin incision is very 
small, on withdrawal not a particle of air enters; 
hence no pneumothorax results. The operation lasts 
but a few minutes, frequently only a few seconds; in 
difficult cases, 5 to 7 minutes; in simple or typical 
cases, 40 to 60 seconds. With one suture the 
button-hole incision is hermetically closed imme- 
diately after the regular dressing is applied. The 
patient is returned to bed, and receives a hypodermic 
injection of 0.02 eg. of morphine, to avoid excite- 
ment upon awakening, and to insure respiratory 
quiet. In cases of large projectiles, the skin in- 
cision is enlarged only when the forceps with the 
projectile in its blades reaches the skin opening, 
which can be enlarged as required. 

In cases of deep projectiles (8 to 12 cm.), the 
author employs an old model, long bullet forceps. 

This sort of instrumentation has given satis- 
factory results in 16 cases, and only in a very few 
cases did any air enter the pleural cavity, or slight 
subcutaneous emphysema result, incidents without 
consequence, all of which the author hopes to 
avoid in the future by using a forceps (on the style 
of Grunwal's) which he is now constructing. 

It sometimes occurs that when the lung is free 
of all attachments, the forceps does not penetrate 
the parenchyma at the first attempt, which occur- 
rence permits of invagination and depression. 
Slight force may be safely used on the visceral pleura 
in order to enter the parenchyma. The organ 
resumes its normal shape and the seizing is easily 
done. The post-operatory sequelae are of extreme 
simplicity. Slight blood expectorations for two or 
three days thereafter are of no importance. 

The day following the operation, the patient 
may sit up in bed. The author's patients left the 
hospital on the fourth day; in a few serious cases 
on the eighth day. All cases were devoid of post- 
operatory pyrexia. The fever curve remained at 
37°C. AH symptoms disappeared in four weeks. 

The author never uses costal resection and never 
has been troubled with pneumo- or haemothorax. 

This technique has been used by the author in 
16 cases, withdrawing 17 projectiles: 9 superficial, 
8 deep (6, 8, 10, 12 cm. deep); 6 in fixed lung, 11 
in free lung. Raoul L. Vioran. 



SURGERY OF THE ABDOMEN 



ABDOMINAL WALL AND PERITONEUM 

Wallace, C. : Tabular Statement of 500 Abdominal 
Gunshot Injuries. Lancet, Lend., 1916, cxc, 502. 

Wallace gives a very interesting tabulation of 511 
abdominal gunshot injuries. The table which is a 



large one shows the nature of the operations per- 
formed, and the character of the lesions encountered. 
The cases were brought to two field hospitals de- 
voted to the care of abdominal wounds, which were 
well advanced to within 5,000 yards of the fighting 
line. Like all statistics gathered so near the front, 



GENERAL SURGERY — SURGERY OF THE ABDOMEN 



31 



the mortality appears greater than one is apt to 
observe further away on the line of communication. 
The principal facts obtained may be summarized 
as follows: 

Total number of cases Sn 

Arrived moribund 14S 

Total mortality excluding the moribimd 45-8 per cent 

Total mortality including the moribund 61.25 P^^ cent 

Considered with view to operation 366 

No operation considered advisable 56 

Total operative mortality 53-9 Per ""^t 

Total hollow viscera mortality 64 . 5 per cent 

Stomach (uncomplicated ) mortality 43 ■ 7 S per cent 

Small gut (uncomplicated) mortality 63 .8 per cent 

Great gut (uncomplicated) mortality 60 per cent 

The next table gives approximately the number of 
times the viscera were injured, the unoperated cases 
not being included. 



Alone of 
Hollow 
Viscera 



With 
Other 
Hollow 
Viscera 
7 



Total 



23 
90 
73 
48 
II 
13 
13 
3 



Stomach 16 

Small gut 69 

Great gut 61 

Liver* 

Spleen 

Kidney 

Bladder 

Ureter 

Pancreas 

* To the 48 cases another 1 5 cases should be added in which the liver 
was almost certainly injured, but in which no operation was performed. 

In the small gut, resection has a higher mortality 
than suture, but this is doubtless due to greater 
initial injury among the resected cases. The actual 
junction line, in the resected cases, rarely gave 
trouble. Three cases of obstruction were due to 
non-toxic paralysis. Resection is to be used instead 
of suture when the saving of time is an object. 
Contused edges were found to heal well and without 
slough, after suture. The soldier's small intestine 
is usually empty — the converse is true of the large 
gut. 

Of 23 stomach wounds only 1 1 were uncomplicated 
by other lesions; the anterior wall was most often 
involved; anteroposterior wounds were not com- 
monly found; extravasation of stomach contents 
was fairly frequent, depending on the time of the 
last meal. 

Of 7 fatal cases of stomach injury, uncomplicated 
by wounds of other hollow viscera, 4 died as a result 
of primary haemorrhage. The author dwells on the 
seriousness of wounds of the epigastric region, and 
he favors operation in all cases. 

The absence of injury to the spleen in stomach in- 
juries was notable and it suggests that such injuries 
seldom live to reach surgical care. 

In the large intestine, the mortality was 60 per 
cent as a result of peritonitis or, perhaps more fre- 
quently, septic infiltration of the retroperitoneal 
tissue. Wounds of the transverse colon are more 
apt to be multiple than those of the other divisions 
of this gut. 

Considering the extent of the injury, the wounds 
of the great gut are much more fatal than those of 
the small gut, no doubt due to the greater toxicity 
of the great gut contents. 

Most of the injuries of the liver were explored for 



haemorrhage. A good many cases might have re- 
covered without operation. 

It is suggested that a good many spleen cases 
recover spontaneously and that it is only when the 
vessels are torn that bleeding is excessive. The 
kidney and spleen seem to be not uncommonly 
injured at the same time, while the stomach nearly 
always escapes. L. A. LaGarde. 

Walker, M. H., Jr., and Ferguson, L. M.: Peri- 
toneal Adhesions; Their Prevention with 
Citrate Solutions. Ann. Surg., Phila., 1916, 
Ixiii, 198. 

The authors have performed more than 100 
experiments upon rabbits with the idea of discover- 
ing the exact effect of hypertonic solutions of sodium 
citrate and sodium chloride upon the peritoneum 
and upon peritoneal adhesions. By careful histo- 
logical examination of sections made of adhesions 
taken from one to fifteen days after operation, they 
find the pathology of adhesion formation is simply 
the process of healing as found wherever tissue has 
been destroyed. 

First, an inflammatory exudate of serum and 
blood is poured out and quickly coagulates. This 
exudate is composed of fibrin with a few red and 
white blood-cells in its meshes. The adherent 
fibrinous exudate is the framework upon which the 
fibrous adhesions are built. Within 48 hours the 
connective tissue and endothelial cells at the base 
of the adhesion begin to proliferate. Fibroblasts 
and new blood-vessels appear very rapidly until, 
at the end of a week, the adhesion is made up of a 
fairly dense fibrous tissue, containing a moderate 
amount of blood-vessels with no inflammatory 
exudate. As time goes on the vessels become 
less numerous and the fibers of the adhesion appear 
to reach in among the muscle-bundles of the muscle- 
coat of the bowel, or of the abdominal wall, as the 
case may be. Meanwhile the endothelial cells of 
the peritoneum have proliferated and covered the 
abdominal surface of the adhesion. The final ap- 
pearance of the adhesion is simply that of a dense 
scar-tissue band covered with peritoneum. 

As the result of their experiments the authors 
conclude that hypertonic citrate solutions do, under 
certain conditions, prevent peritoneal adhesions 
after laparotomy. The best solution is sodium 
citrate 3 per cent and sodium chloride i per cent. 
Theoretically in human surgery, after clean lapa- 
rotomies, a sufl&cient amount of solution should be . 
introduced into the abdomen to bathe the whole 
peritoneum (500 to 600 ccm.) and smaller amounts 
would be of little value. 

The authors have not used the solution in human 
surgery and suggest that the question of shock must 
be considered and determined by actual tests in the 
operating room. They believe that if gauze packs, 
used to wall off the intestines, are wet in citrate 
solution, much fewer adhesions will result. Adhe- 
sions cannot be prevented in the presence of infec- 
tion by any known method. Large areas of denuded 



32 



INTERNATIONAL ABSTRACT OF SURGERY 



peritoneum should be covered by plastic operations, 
for the larger the denuded areas left, the greater 
the likelihood of adhesion formation. Iodine 
should be used with great care as very little, if 
allowed to touch the bowel, causes masses of adhe- 
sions. Dry gauze should not be used inside the 
abdomen. Gatewood. 

Pope, S. : The Prevention of Peritoneal Adhesions 
by the Use of Citrate Solution. Ann. Surg., 
Phila., 1916, Ixiii, 205. 

Two years ago, the author advocated the use of 
sodium citrate with sodium chloride in solution 
for the prevention of peritoneal adhesions. His 
reasons were based upon experimental work done 
upon rabbits. Since that time, with Wallace Terry, 
he has used a solution of citrate of soda 2 per cent 
with sodium chloride 2 per cent in some 400 ab- 
dominal sections. In about 20 cases from four 
ounces to a pint of this solution was left in the 
abdominal cavity. In the other cases, the gauze 
pads and sponges were moistened with the solution. 
There is no evidence to show that the liability to 
infection is increased by this treatment, but, on 
the contrary, where peritonitis is present, a marked 
improvement seems to have occurred. The quan- 
tity of solution was left in the abdominal cavity of 
such cases as general post-operative adhesions, 
acute obstructions, pus-tubes, colectomies, resec- 
tions, and tuberculous peritonitis. The abdominal 
wounds show more oozing during closure in these 
cases, but in no case was there evidence of post- 
operative haemorrhage or failure of union. This 
procedure causes pain and partially rouses the 
patient, so that it has been found expedient to 
have the incision almost closed before introducing 
the liquid. Ten of their cases have been reopened 
so that the benefits could be judged by inspection. 
The purpose of the citrate is to abolish excessive 
fibrin deposit with subsequent adhesion formation 
as it will not prevent inflammatory repair. 

Gatewood. 

Bayne- Jones, S.: Eventration of the Diaphragm, 
with Report of a Case of Right-sided Eventra- 
tion. Arch. Int. Med., 1916, xvii, 221. 

The author reports a case of eventration of the 
right side of the diaphragm. This diagnosis, made 
from physical examination, was the first of its kind 
determined during the life of the patient. The 
clinical impression was confirmed at operation. 

The author has collected from the literature 45 
cases of eventration of the diaphragm. Of these, 
3 were right-sided and 42 were left-sided lesions. 

In the differential diagnosis between eventration 
and allied states, the author points out difficulties, 
particularly with regard to the differentiation from 
hernia of the diaphragm. He believes that no 
single method is capable of establishing this dif- 
ferentiation, but the combined methods render the 
diagnosis reasonably certain. 

He summarizes the various etiological hypotheses, 



showing that the weight of evidence is in favor of 
the opinion that the disease has a congenital origin. 

George E. Beilby. 

GASTRO-INTESTINAL TRACT 
Dewis, J. W,: Aids in the Diagnosis of Surgical 
Conditions of the Stomach with Especial 
Reference to the Characteristic X-Ray Ap- 
pearance of the Syphilitic Hour-Glass in Con- 
trast to Those of Simple Ulcer and Cancer. 
Canad. M. Ass. J., 1915, v, 1056. 

The author believes that the greatest single 
aid in detecting cancer of the stomach and in differ- 
entiating this from ulcer is the X-ray. It is not 
easy to differentiate cancer from syphilitic ulcer of 
the stomach, and even the X-ray may fail to detect 
cancer near the cardia. In the lower two-thirds 
of the stomach, the X-ray examination ought to 
show cancer in every case, if properly done and 
correctly interpreted; and in the majority of cases 
it will detect cancer earlier than clinical methods. 

On the other hand, to determine whether cancer 
of the stomach is surgical, and when inoperable, 
while the X-ray is a valuable aid, the chief means 
are the ordinary methods and the experience and 
judgment of the clinician. The author thinks that 
surgery should be the treatment in all early cancers 
of the stomach; but that the reverse is true in ulcer 
of the stomach and duodenum except where there 
are acute perforated ulcers. 

Regarding chronic ulcers, whilst some extreme 
internists are so convinced of the probability of 
ulcers healing that they would persist in the medical 
treatment of practically all ulcers, yet it does not 
seem likely that an ulcer of the stomach or duode- 
num with a history of twenty or thirty years' dura- 
tion can be cured with a month or two of medical 
treatment of any kind. 

Chronic ulcers of the stomach become surgical 
under these conditions: when there is chronic 
pyloric obstruction not relieved by medical means; 
when there is permanent hour-glass contraction; 
in the cases where pain and distress, sour regurgita- 
tions, and intractable dyspepsia do not yield to treat- 
ment ; and finally when there are severe haemorrhages. 

In syphilis of the stomach the first clue is a history 
of infection confirmed by the Wassermann test and 
the X-ray. The X-ray is most valuable in a differ- 
entiative test. Pictures of syphilis do not show the 
moth-eaten appearance of cancer and there is much 
more involvement of the stomach wall than in 
simple ulcer. But the characteristic point that 
differentiates syphilis from cancer and simple ulcer 
is that in syphilitic hour-glass stomach a long regular 
isthmus is seen, at each end of which the walls of 
the stomach rise more or less abruptly or dumb- 
bell like. This is in contrast to the sharp incision of 
simple ulcer hour-glass with practically no isthmus; 
and the picture differs quite as much from the 
cancer hour-glass with the infiltrated walls of the 
stomach sloping irregularly away from the con- 
stricted portion. Hollis E. Potter. 



GENERAL SURGERY — SURGERY OF THE ABDOMEN 



33 



Squires, J. W. : Roentgen -Ray Diagnosis of Gastric 
Lesions. N. Y. M. J., 1915, cii, 1227. 

For the purpose of roentgen ray study the 
author divides stomach lesions into two groups. 
The first includes tumors, chronic ulcers, adhesions, 
and syphilis, lesions which produce permanent de- 
fects in the stomach contour. In the second group 
are included acute simple ulcers and exogastric 
lesions or lesions which produce spasmodic stomach 
defects only. In either class a positive diagnosis 
cannot be made without the aid of the roentgen 
ray. 

In early carcinoma the radiographic findings are 
very similar to those in ulcer; and at this stage 
it is impossible to determine by the X-ray whether 
or not malignant degeneration has occurred. From 
an X-ray standpoint, however, the important line 
of division is not between benignancy and malig- 
nancy but to determine whether the lesion has 
advanced sufficiently to become a surgical case. 
This stage is determined by the production of 
permanent defects in the contour, six-hour stasis, 
and interruption of normal peristalsis. The author 
emphasizes the importance of careful observation 
of gastric ulcers in the precancerous stages, as on its 
early recognition depends successful treatment. 

Radiograms are taken immediately after a test 
meal and every half hour after or even more fre- 
quently until sufficient data are obtained. This is 
followed by fluoroscopic examination. 

The diagnosis of gastric carcinoma requires a 
very careful consideration of the radiographic and 
fluoroscopic observations. The characteristic find- 
ings in order of importance are: (i) filling defects; 
(2) absence of peristalsis in part involved; (3) mo- 
bility; (4) superimposing test; (5) pain at site of 
filling defect (fluoroscopic); (6) changes in the 
pylorus; (7) residue; and (8) advanced position of 
test-meal in six hours. 

The filling defect is the most valuable as it is 
constant and is not affected by stomach peristalsis. 

The various characteristic findings are shown in 
illustrations accompanying the article. 

The diagnosis of gastric ulcer is similarly based 
on radiography and fluoroscopy. In the case of 
chronic ulcer the following signs are basic: (i) per- 
manent irregularities in contour of stomach or cap; 
(2) interruption of peristaltic contractions; (3) in- 
cisura; and (4) locating pain directly over defect 
(fluoroscopic). Hollis E. Potter. 

Palmer, C. L. : The Significance of Certain Rcent- 
genographic Findings in the Gas tro- intestinal 
Tract. /. Am. M. Ass., 1916, Ixvi, 493. 

Normally the stomach can change its position 
without the help of alteration in body posture. 
When this mobility of the stomach is lacking, it is 
either due to restraining forces which prevent the 
movement, or else to lack of power to move. The 
former is the most frequent cause for lack of change 
of position of the stomach. 

Persistent supraposed stomach is due to a re- 



straint and not to lack of power. This restraint is 
most frequently exercised by adhesions due chiefly 
to cholecystitis, chronic appendicitis, traumatism 
(previous operation), or gastritis due to syphilis, 
cancer, or ulcer. 

Persistent infraposed stomach is not as frequent 
as supraposed stomach. It is caused by restraint 
or lack of power to move, most frequently lack of 
power, which is the case in chronic gastro-enter- 
optosis with relaxation of the abdominal walls. 

Long retention of the gastric contents (twenty- 
four hours or longer) is chiefly due to one cause, 
namely, cancer of the stomach. The other chief 
cause is long-standing chronic cholecystitis. Re- 
tention for a shorter time (six to twenty-four hours) 
has for its most frequent causes cicatricial contrac- 
tion of the pylorus due to healed ulcers, chronic 
appendicitis, chronic cholecystitis, typhlitis, and 
syphilis. 

Pylorospasm does exist, but it is not always 
present when extragastric lesions are prevalent. 
It probably depends on the reflex excitability of the 
individual's nervous system. 

Diagnoses made by judging from the roent- 
genograms, together with the history of the case 
and other clinical evidence obtainable, are correct 
in nearly every case. This was demonstrated in 
the majority of the cases by subsequent operation or 
necropsy. In most of the others it was shown with 
a satisfying degree of probabiHty by the subsequent 
course of the case. 

Roentgenograms have revealed certain facts 
which can be demonstrated by other means. The 
most prominent of these are the obstructive lesions 
which are, as a rule, located either in the pylorus of 
the stomach or in the region of the caecum and are 
usually due to definite conditions. 

By the use of the stomach-tube in gastric analy- 
sis, fascal examinations, the charcoal test, Bastedo's 
test, and careful analysis of clinical symptoms and 
physical signs, it is possible, in a certain number of 
cases, to make a very accurate diagnosis without the 
use of the ray. In all cases which are readily diag- 
nosed without the ray, however, roentgenograms 
should be taken and carefully interpreted along with 
laboratory tests, clinical history, and physical 
findings, in order to obtain a clear diagnosis. 

Edward L. Cornell. 

Mann, F. C: A Study of the Gastric Ulcers Fol- 
lowing Removal of the Adrenals. /. Exp. 
Med., 1916, xxiii, 203. 

Mann noted at autopsy that animals dying after 
the removal of both adrenals showed acute ulcera- 
tion of the gastric mucosa in a large number of 
cases, and he states that other investigators have 
noted similar results. As no lesion of the gastric 
mucosa was found at autopsy in a series of more than 
200 practically normal animals, it seemed to the 
ajUthor that spontaneous ulcers were not common 
in these animals. He therefore subjected a large 
series of animals to adrenalectomy and the results 



34 



INTERNATIONAL ABSTRACT OF SURGERY 



were studied. The lesions he found in the gastric 
mucosa after death from adrenal insufficiency con- 
sisted of two main types, one a wide-spread, super- 
ficial erosion, the other a true, punched-out ulcer 
formation. The gastric erosions practically always 
occurred in the fundic division, and in most cases, 
the author states, the pyloric mucosa appeared 
normal. The duodenal mucosa was usually con- 
gested in the adrenalectomized animals, and in 
several instances there were definite ulcers. These 
duodenal ulcers occurred just distal to the pyloric 
ring and appeared like cauterized areas about 1.5 
cm. in diameter. They were deeper at the center 
than at the edges, penetrating to the muscularis 
mucosa at the center, and they showed no evidence 
of haemorrhage. 

To summarize briefly, acute ulcers of the gastric 
mucosa are found in a large percentage of dogs and 
cats dying after adrenalectomy. These ulcers seem 
to develop during the moribund period. They are 
apparently peptic ulcers forming at the site of local 
haemorrhages in the gastric mucosa. They are true 
acute ulcers, usually penetrating to the muscularis 
mucosa with a total loss of epithelium. They de- 
velop in the absence of pancreatic secretion and bile. 
However, they appear to develop only in an acid 
medium. George E. Beilby. 

Friedenwald, J.: The Modem Method of Treat- 
ment of Diseases of the Stomach. Therap. 
Gaz., 1916, xl, 77. 

The treatment of diseases of the stomach was 
discussed with regard to the use of the stomach- 
tube, with regard to the diet, to the use of medicinal 
agents, of mechanical supports, of mineral water 
cures, and with regard to surgical measures. 

Freidenwald classified the indications for opera- 
tion under three heads, as follows: 

1. Obstructions. Gastrostomy is indicated in 
impermeable stricture of the cardiac orifice or of 
the oesophagus. In benign obstruction of the 
pylorus, pyloroplasty, gastro-enterostomy, or py- 
lorectomy is indicated. In malignant disease 
pylorectomy is indicated for cure and gastro- 
enterostomy for relief. 

2. Gastric ulcer. The indications for operation 
are perforation, pyloric obstruction, and ulcers 
resisting medical cures. The operations indicated 
are excision of the ulcer, pylorectomy, pyloroplasty, 
or gastro-enterostomy. 

3. Gastric carcinoma. An exploratory incision 
should be urged in all cases over 40 years of age 
with manifest symptoms of indigestion which are 
not relieved by a few weeks of medical treatment 
and in which the diagnosis is still doubtful after a 
thorough examination. J. W. Turner. 

Case, J. T.: Roentgen Studies After Gastric and 
Intestinal Operations. /. Am. M. Ass., 1915, 
Ixv, 1628. 

For several years Case has pursued the roent- 
genologic study of patients after gastric and in- 



testinal operations. The results of this study are 
given under the headings: (i) Acute small bowel 
obstruction; (2) gastro-enterostomy; (3) appendec- 
tomy; and (4) ileocolostomy. 

Experience has shown the value of roentgen 
examination in the diagnosis of post-operative acute 
small bowel obstruction with special reference to 
the decision as to the advisability of surgical inter- 
ference. No barium or opaque meal is usually 
given, the observations being made by the gas 
distention of the intestine. 

After gastro-enterostomy it has been believed that 
the rapid exit of food from the stomach was pre- 
vented by the formation of rythmically contracting 
constriction rings in the duodenum. The author 
has observed analogous action in a large number of 
cases in which the ordinary gastrojejunostomy had 
been performed; viz., a sort of sphincter action 
established in the jejunum at a point varying from 
3 to 6 ccm. below the gastrojejunal opening. 

Case says that after gastro-enterostomy there is 
a stagnation of food in the jejunum near the site 
of the gastro-enterostomy, due to the inhibition 
of onward peristaltic activities at this point. 

The occurrence of caecal stasis following ap- 
pendectomy is very common. Case believes that 
retention occurs at the site of the stump of the 
appendix, and that it has some relation to the in- 
vaginating suture by which the stump is usually 
buried. 

Most of the cases examined, all in fact except 
those cases in which an artificial ileocolic valve had 
been formed, have shown incompetency of the 
ileocolic stoma permitting an enema to flow back 
into the small bowel as well as retrogradely around 
the colon to the caecum as far as the stump of the 
colon. In long operated cases especially there is 
very definite ileal stasis. 

From his studies Case states that in a very con- 
siderable percentage of cases in which the operation 
of ileosigmoidostomy is performed for the relief 
of intestinal stasis, the end-result is infinitely worse 
than if the patient had not been operated on, at 
least as far as the stasis is concerned. 

HoLLis E. Potter. 

Downes, W. A.: Operative Treatment of Pyloric 
Obstruction in Infants; Review of Sixty-Six 
Cases. Surg.,Gynec. &" Obst., 1916, xxii, 251. 

The author reports 66 cases operated upon in 
five and one-half years. All presented the char- 
acteristic symptoms. A tumor was palpated in 
every case before operation. 

The theory best explaining the symptom-complex 
is that a true malformation is present at birth con- 
sisting of an abnormal thickening of the circular 
muscle of the pylorus, and to this is added an 
oedematous condition some ten days, or later, after 
birth. The oedema probably results from the 
increased activity of the stomach necessary to 
force an increasing amount of food through the 
narrowed and elongated pyloric lumen. 



GENERAL SURGERY — SURGERY OF THE ABDOMEN 



35 



Gastro-enterostomy was performed upon 31 of 
the 66 cases, the remaining 35 being operated 
on according to the Rammstedt method. Of the 
31 cases in which gastro-enterostomy was done 
there were 11 deaths — a mortality of 35 per cent. 
Of the 20 discharged as cured, 2 afterwards died of 
gastro-enteritis and i died of diphtheria. The 
remaining 1 7 are well and have developed normally. 
Roentgen-ray examination shows the stomata 
working satisfactorily, and little or no bismuth 
passing through the pylorus. 

Not satisfied with the results from gastro-enter- 
ostomy it was decided to try the partial pyloroplasty 
of Rammstedt. Consequently, this operation has 
been done in the last 35 cases. In this series there 
were 8 deaths, a mortality of 23 per cent. Of the 
27 cases discharged as cured, 2 have died since 
leaving the hospital, the remaining 25 are well 
extending over a period from a few weeks to one 
and one-half years. In no case has there been a 
return of the symptoms. 

The cases operated on according to the Rammstedt 
method vomited less and were easier to feed after 
operation. 

The advantages of the partial pyloroplasty over 
gastro-enterostomy are: (i) time consumed for 
operation, the former requiring less than half the 
time necessary to perform the latter; (2) the opera- 
tion requires much less surgical skill than gastro- 
enterostomy; and (3) the continuity of the gastro- 
intestinal tract is preserved. Roentgen- ray exam- 
ination one and one-half years after operation and 
autopsy on one case dying three months after 
operation demonstrates the fact that the stomach 
functionates normally, and that the tumor entirely 
disappears after this procedure. 

Jefferson, G. : Ulcer of the Duodenopyloric Fornix. 

Ann. Surg., Phila., 1916, Ixiii, 328. 

As is well known, duodenal ulcers have a peculiar 
partiality for that part of the duodenum immediately 
adjoining the stomach, and the probable role of the 
gastric juice in the production of these ulcers is 
obvious. The pylorus when viewed from the duod- 
enum appears as a knoblike projection formed by 
the massive muscular ring which constitutes the 
pyloric sphincter. The furrow which surrounds 
this knob is termed the duodenopyloric fornix. 
The depth of this sulcus varies considerably, being 
shallow in relaxed hypotonic stomachs, and espe- 
cially well marked in duodenal ulcer where gastric 
hypertonus is the rule. Owing to the absence of 
valvulae conniventes in the suprapapillary duod- 
enum, the examination of the interior of this part 
is relatively easy, and it is almost impossible to 
overlook an ulcer, unless it be situated on the 
posterior wall and hidden by the projecting pylorus. 

The author believes that the duodenopyloric 
fornix is a frequent site of ucler, and that ulcers 
usually classed as "pyloric," a term which suggests 
gastric origin, are really duodenal. Chronic ulcers 
of the stomach rarely involve the pyloric canal, 



most of them being some distance from the pylorus, 
while duodenal ulcers become more frequent as the 
pylorus is approached. The result of ulcer in this 
location is the destruction of the usual landmarks, 
making it very difficult to tell the exact point of 
origin of such an ulcer. Cases are now on record 
in which the duodenal ulcer has been quite healed, 
while its invasion of the pylorus has become 
malignant. The great difference in the frequency 
of carcinoma following duodenal and gastric ulcer 
makes differentiation extremely important. 

Gatewood. 

Bryan, R. C. : Ulcer of the Jejunum. Surg., Gynec. 
d'Obst., 1916, xxii, 279. 

Ulcer of the jejunum is apparently a most rare 
condition, there being only four cases recorded in the 
literature which arose de novo and independent of a 
previous gastro-enterostomy. The author's case 
was that of a man 48 years old, with a history of three 
years' duration of gastric pain which had been diag- 
nosed as ulcer of the duodenum. He was suddenly 
taken with severe abdominal pain, followed by 
collapse; 17 hours later operation was performed. 
The stomach was bound down, hard, atrophic, 
pulled to the left and firm. About 3 inches from 
the duodenojejunal juncture a round punched-out 
ulcer about the size of a cherry stone was found. 
The patient died the following morning. 

Diagnosis of this condition apparently must be 
based upon deduction derived from observations 
of jejunal ulcers forming after a previous gastro- 
enterostomy. According to the more recent the- 
ories these ulcers develop from autodigestion of 
the mucosa by an acid action which has been poorly 
modified by the alkaline products of the upper gut. 

This has, in a measure, been corroborated by the 
experimental work of Exalto, Kathe, Wullenstein, 
and more recently by Soresi of New York. Wilkie 
has done some interesting experimental work on 
dogs in which he performed gastro-enterostomies 
administering various amounts of hydrochloric acid, 
thus noticing the development of jejunal ulceration. 
The author is not certain but that there is an 
association of this condition also with the state 
"linitis plastica," the gastro-intestinals clerostenosis 
of Krompecher. In appropriate cases excision, 
resection, or enterectomy are apparently the 
operations of choice. 

Deaver, J. B.: Acute Appendicitis. N. Y. M. J., 

1916, ciii, 241. 

Appendicitis is the most common intra-abdominal 
inflammation and the appendix constitutes the 
avenue by way of which infection most commonly 
invades the upper abdomen. There are three peri- 
toneal fossae in relation to the appendix, the ileocolic, 
the ileocaecal, and the subcaecal, the appendix being 
occasionally buried in one of the last two, thus ex- 
plaining why the organ is believed to be absent. 
The author has never failed to find an appendix in 
the many cases he has operated upon. 



36 



INTERNATIONAL ABSTRACT OF SURGERY 



The appendix may be found below and to the 
outer side of the caecum, to the outer side of the 
caecum and colon, pointing upward and outward, 
behind the caecum pointing upward; to the inner 
side of the caicum, lying beneath or above the ter- 
minal mesentery of the ileum; and pointing down- 
ward, occupying the false and even the true pelvis. 
Thus the location of the point of tenderness and of 
referred pain must differ in particular cases, and 
symptoms pointing to gall-bladder, duodenal, 
pyloric, pancreatic, or pelvic disease may arise. 

The etiological factors of importance are: age, 
previous attacks of appendicitis, catarrhal conditions 
of the gastro-intestinal canal, infectious diseases, 
especially influenza, and digestive disturbances, 
the latter resulting in a great increase in the bacterial 
flora of the intestine. 

The peritoneum defends itself by the function 
of exudation and absorption, the former enabling 
it to form adhesion of a protective character, and 
any treatment that breaks down these adhesions, 
such as purgation, defeats that protective function 
and may be harmful in the extreme. 

Appendicular abscesses are met with in several 
situations: (i) in front of, below, and to the outer 
side of the caecum, the pus being confined by the 
caecum, small bowel, omentum, etc.; (2) to the 
outer side of the caecum and ascending colon or be- 
hind the caecum in the layers of the mesocolon; (3) 
in the pelvis; (4) near the median line to the median 
side of the caecum; (5) free in the abdominal cavity 
or existing in the shape of many pockets between 
the coils of intestines. In addition there are seen 
secondary abscesses, which occur close to the 
original abscess, residual abscesses occurring at the 
site of the primary abscess, and metastatic abscesses, 
which occur at any point distal to the site of the 
original, or as a parotid abscess, pyelophlebitis, etc. 

The clinical history is typical, a previously well 
individual being seized with acute abdominal pain, 
first referred to the umbilical or epigastric region 
and accompanied by vomiting. The pain soon 
becomes localized to the right iliac fossa and 
muscular rigidity is noted. If this sequence is 
interrupted, the diagnosis of acute appendicitis 
may be doubted. Fever is always present. If the 
appendix is in the pelvis the pain is likely to be 
left-sided. Suddenly subsiding pain followed by a 
chill points to gangrene, while exquisite tenderness 
denotes the presence of pus. The differentiation of 
importance lies between acute cholecystitis and 
appendicitis. 

The treatment is comprehended in the following 
points: (i) examine the patient thoroughly and not 
through the clothes; (2) give no aperient medicine; 
(3) V12 to V16 grain of morphine will not mask the 
symptoms and may be safely given when the pain 
is severe; (4) the diagnosis having been made the 
proper measure is immediate operation. In the 
presence of peritonitis and in the absence of opera- 
tion, set the patient up in bed, give nothing by 
mouth, place an ice-bag over the tender area, and 



institute enteroclysis. Operate in the cases of 
localized peritonitis where the lesion can be local- 
ized and there is peristalsis in the surrounding region 
of the abdomen. In diffused peritonitis defer 
operation until the peritonitis becomes a localized 
one. E. K. Armstrong. 

Mayo, W. J.: Radical Operation for Cancer of 
the Rectum and Rectosigmoid. Tr. Am. 

Surg. Ass., Washington, 1916, May. 

The author discusses (i) operability, (2) operative 
mortality, (3) operative disability, (4) function fol- 
lowing operation, and (5) permanent cure, on the 
basis of a study of 753 cases of cancer of the rectum 
and rectosigmoid examined in the Mayo Clinic 
between January i, 1893, ^.nd December 31, 191 5. 
Of these, 430 were subjected to radical operation. 

Six hundred and nineteen cases gave an opera- 
bility of 53.1 per cent. Radical operation was 
seldom refused because of the local extent of the 
disease. Had it been possible to know the extent of 
the disease previously in some instances, patients 
would not have been operated on, though many in a 
very advanced stage were cured. Lymphatic in- 
volvement is usually late and in no case was lym- 
phatic extension alone the cause of inoperability. 
Theoretically, the abdominal cavity should be 
explored in every case because of the frequency of 
metastasis in the liver and peritoneal cavity. In 
very obese patients the posterior Kraske operation 
in one stage may be wise. 

In 430 radical operations the operative mortality 
was 15.5 per cent. During the last three years, in 
spite of the fact that 71.8 patients in each 100 were 
operated on, the mortality has been reduced to 12.5 
per cent; it has now been brought to about 10 per 
cent. In cases in which the disease in the rectum was 
movable the mortality was under 5 per cent. All 
patients dying in the hospital are classified as cases 
of operative mortality, without regard to length of 
time that death occurred after operation. Necropsy 
was secured on 95 per cent of patients dying in the 
hospital. The mortality in any given statistical 
group is low with low operability; high operability 
includes cases of advanced disease which greatly 
increase the mortality. Comparative statistical 
data of operative mortality means nothing unless 
the total number of patients examined, whether 
operated on or not, is taken into consideration. 

The causes of operative mortality are: (i) sepsis, 
39.8 per cent, usually due to soiling of the operative 
field with the infected contents of the involved bowel 
because the rectum had become fixed and the growth 
had penetrated its walls; (2) nephritis, 13 per cent 
acute, developing on chronic; (3) metastatic tumors 
undiscovered on exploration, 10.5 per cent (had the 
true condition been known operation should have 
been performed); (4) death from haemorrhage, 6.5 
per cent, in no case immediate, but blood-loss led to 
exhaustion, sepsis, etc. No case of shock without 
haemorrhage. Secondary haemorrhages were not 
truly secondary, but rather a continuation of badly 



GENERAL SURGERY — SURGERY OF THE ABDOMEN 



37 



controlled haemorrhages; (s) death due to exhaus- 
tion, etc., often some days or weeks after operation. 

When aseptic healing took place, patients were 
discharged from the hospital as early as sixteen days 
and returned to work in thirty days. Infected 
wounds healed in from four to twelve weeks but the 
patients were not able to return to work for three or 
four months. 

The best function followed the tube resection 
described by Balfour and the C. H. Mayo method 
of direct end-to-end union. The Wier invagina- 
tion method gave excellent results when it could 
be used. In the Gripps operation, although the 
entire sphincter was removed, the functional results 
" were as a rule excellent. In the majority of cases 
the radical operation necessitated a colostomy in 
the abdomen, or a posterior anus more or less un- 
controllable. The Mixter midline colostomy proved 
most satisfactory. 

As to permanent cures, of the 430 patients on 
whom a resection was done, 364 recovered from the 
operation. Eliminating those who were operated 
on less than three years ago, 33.3 per cent have lived 
three years or more, and 28.3 per cent have lived five 
years or more after the operation. These percent- 
ages may be fairly increased to 37.5 and 35.8 per 
cent, respectively, by subtracting from the mor- 
tality figures the normal death-rates for corres- 
ponding ages for periods of three and five years, 
i.e., 4.2 and 7.5 per cent.^ 

LIVER, PANCREAS, AND SPLEEN 

Collins, C. U. : Indications for Cholecystectomy and 
Cholecystostomy. Illinois M. J., 1916, xxix, 210. 

Letters were sent to 147 patients who had re- 
covered from cholecystostomies, asking if they 
had had any trouble with the gall-bladder or stom- 
ach since the operation. In all 102 replies were 
received: 74 said they had been perfectly well, so 
far as the gall-bladder and stomach were concerned; 
15 complained of some pain in the gall-bladder or 
stomach, or both, while 13 complained of still 
having severe pain at times in the region of the 
gall-bladder or stomach or both. . 

Conclusions are drawn from 196 cases: 

1. The presence or absence of stones in the gall- 
bladder should not be considered in deciding to 
remove or leave a gall-bladder. It is entirely a 
question of infection. 

2. An infected gall-bladder had better be re- 
moved if there are no contra-indications. 

3. The location of a stone in the common duct 
may be a factor in the decision. If it has caused 
a recent attack of jaundice, a possible pancreatitis 
should be considered, and, if present, the gall- 
bladder should be retained and drained, at least 
temporarily. 

4. An acutely inflamed gall-bladder due to a 
virulent infection, evidenced by the clinical symp- 
toms, had probably better be retained and drained. 

' Medico-actuarial mortality investigation table. 



A cholecystostomy is safer in these acute cases than 
a cholecystectomy. A cholecystectomy may be 
safely done after the acute symptoms have sub- 
sided, if it is necessary. 

5. The small proportion of gall-bladders which 
contain stones with no present evidence of infection 
may be drained, although it may be safe in these to 
open the gall-bladder, remove the stones, and close 
it without drainage. 

6. The general condition of the patient may 
make a simple cholecystostomy the wiser procedure 
until the general condition improves. 

7. The history is not only the largest element in 
making the diagnosis, but is also of great importance 
in deciding the question of removing or retaining 
the gall-bladder. If the history shows persistent 
symptoms, indicating chronic infection, the gall- 
bladder had better be removed. 

8. In spite of these conclusions it takes the high- 
est surgical judgment to decide, at times, which 
will give the most ultimate benefit to the patient, 
the retention or removal of his gall-bladder. 

Edward L. Cornell. 

Bazy, M.: End-Results of Entero-biliary Anasto- 
mosis (Resultas eloignes des anastomoses entero- 
biliares). Bull. Acad. d. mSd., 1916, Ixxv, 35. 

Bazy reports two rare operations: (i) hepatico- 
duodenostomy for obliteration of the common duct 
at the summit of Vater's ampulla; (2) choledoco- 
duodenostomy for obliteration of the terminal 
portion of the common duct. He has only been able 
to find three similar cases in the literature and little 
is known of the end-results. Two of these cases 
were reported by Terrier at the French Surgical 
Congress, 1908. 

In the two cases reported by the author both pa- 
tients were women and Bazy has been able to trace 
their history for sixteen months and eight years 
respectively after operation. In the latter case the 
woman became pregnant a little more than a year 
after operation, and was delivered of twins at term 
without any trouble. In her case the anastomosis 
has functioned well, and at no time during the past 
eight years has the integrity of the bile passages or 
the functioning of the kidneys been menaced. 

In the discussion Branet mentioned a similar 
operation in a case where the lower half of the com- 
mon duct was almost completely obliterated and 
the upper half was anastomosed to the duodenum. 
One year later there was reappearance of icterus 
with other troubles and the patient died. 

A. Goss. 

Mapes, C. C: Uncertainties of Understanding 
Anent Cholelithiasis. Am. J. Surg., 1916, xxx, 
54- 
The author reaches the following conclusions: 

1. That there are many uncertainties of under- 
standing anent the etiology, histopathology, symp- 
tomatology, and treatment of cholelithiasis. 

2. That the hypothesis that bacterial invasion 



38 



INTERNATIONAL ABSTRACT OF SURGERY 



represents the terminal rather than the primary- 
factor in cholelithiasis has been clearly disproved. 

3. That the medicinal treatment of cholelithiasis 
is a delusion, there being no drug which internally 
administered will cause disintegration of definitely 
formed choleliths. 

4. That the most favorable results may be 
expected to accrue from cholecystostomy , cholelithot- 
omy, and temporary drainage. 

5. That cholecystectomy is illogical and unwar- 
ranted except where the cholecyst is already 
damaged beyond hope of functional restoration or 
is involved in demonstrable malignancy. 

C. G. Heyd. 

Einhorn, M.: Pancreatic Stone Colic (Zur Klinik 
der Pankreassteinkolik). Berl. klin. Wchnschr., 
1916, liii, no. 

Pancreatic stones are rarely observed in the 
human organism and their diagnosis during life is 
rarer still. Einhorn reports two cases which he has 
had under his observation. 

Of the diagnostic signs the occurrence of colic-like 
pain in the epigastric region which is associated with 
a transient appearance of sugar in the urine is the 
most characteristic. This pain is periodically re- 
peated and its sudden cessation speaks of the passing 
off of the stone. The appearance of a stone in the 
faeces consisting chiefly of calcium carbonate without 
cholesterin or bile pigment points to its pancreatic 
origin. 

As a general rule the pancreatic function is not 
disturbed for a long time. Later there are disturb- 
ances wh"ch lessen the pancreatic activity. While 
the occasional appearance of sugar in the urine 
during an attack of colic is very important, it is 
not a sine qua non in the diagnosis of pancreas stone. 

If the ordinary methods of medical treatment fail 
and attacks are frequently repeated and become 
more severe in character, operatory interference is 
indicated. The gall-bladder and pancreas should be 
carefully examined and if stone is present it should 
be removed. Frequently the palpation of small 
stones even in the exposed pancreas is not possible. 
The gall-bladder should always be drained because 
much drainage has a favorable effect upon an exist- 
ing pancreatitis in the case of calculi. 

W. A. Brennan. 

Mayo, W. J.: The Spleen; Its Association with the 
Liver and Its Relation to Certain Conditions 
of the Blood. /. Am. M. Ass., 1916, Ixvi, 716. 

The regularity with which splenic enlargements 
and other physical changes occur in association with 
diseases of tlae liver and of the blood has strongly 
impressed the author who, whenever possible, 
during an abdominal section examines the spleen. 
The examination of this organ by external means is 
often misleading and can never be relied on, 
although the X-ray offers some hope in the diagnosis 
of splenic pathology. 

Investigation has shown that not only does the 
spleen extract bacteria and other toxic agents 



from the blood but also conserves the food value 
of broken down blood-cells by sending their rem- 
nants to the liver for further elaboration. But 
whatever the function of the spleen is it must send 
its products through the splenic vein to the liver. 
This close association is well shown by the splenic 
hypertrophy attendant on liver cirrhosis and second- 
ary liver cirrhosis in the Banti stage of splenic 
anaemia. 

That the liver may adequately maintain this 
function of conservation, it has been given the 
power of regeneration. In all other organs of the 
body this power is practically nil, hypertrophy 
taking its place. 

Adami points out that in the liver the bacteria 
that have escaped the leucocytes are destroyed, 
giving rise to pigmented areas, and Vaughan advances 
the theory that bacteria are not vegetable but 
parasitic organisms, and that diseases such as ty- 
phoid and the preventive serums act to educate 
the cells of the body to resistance against certain 
organisms and to so change the body proteins that 
they are no longer bacterial food. 

Rosenow further demonstrates the selective 
affinity of bacteria and other substances for certain 
tissues or organs. Is it not probable that the spleen 
has the power of attracting certain substances in 
the blood as shown by splenic enlargements of 
typhoid, malaria, etc.? 

Moreover the spleen has no internal secretion, as 
removal does not deprive the body of an important 
constituent; nor is it under complete nervous con- 
trol through scanty nerve-fibers from Auerbach's 
plexus. It does, however, contain much non- 
striated muscle which is possibly responsible for the 
digestive rhythmic change in size. 

As to the relation of the spleen to blood, normally 
in the foetus, the spleen, liver, adenoid, and lym- 
phoid structures are blood-producing organs; this 
power, in the spleen at birth, diminishing to the 
production of white cells. 

In the various anaemias, the spleen acts as a grave- 
yard for the blood-cells, especially the red, not 
through its own initiative but as though the cor- 
puscles were sensitized in some other place and 
destroyed in the spleen. Thus, the enlarged spleens 
so often found in these conditions may be a work of 
hypertrophy and it would appear that possibly this 
excess of splenic tissue, or hypersplenism, may cause 
an unnecessary destruction of the red cells, there 
being many exciting causes for the onset of splenic 
enlargements; for example, the relief of the second- 
ary anaemia in syphilis, particularly of the liver, 
by the removal of the enlarged spleen. 

In so-called primary tuberculosis of the spleen, 
the removal of the organ has occasionally benefited 
a few. It is likely, however, that the disease is 
never primary in the spleen, and such a diagnosis 
is rather the result of insufiicient clinical study. 

In the anaemia of chronic syphilis remarkable 
improvement followed the removal of the enlarged 
spleen. In chronic septic conditions with enlarged 



GENERAL SURGERY — SURGERY OF THE EXTREMITIES 



39 



spleens, removal does not bring satisfactory results 
as there is usually a very lowered resistance and a 
cardiorenal insufficiency to overcome. 

In splenic enlargements associated with hepatic 
disease it is often impossible to determine whether 
the process is primary in the spleen or liver. In 
Hanot's cirrhosis, when diagnosed, undoubted 
benefit follows removal of the spleen. 

In 4 cases the author has removed an enlarged 
spleen in conditions of portal cirrhosis of the liver, 
with much relief of the symptoms. 

It must always be borne in mind that the spleen 
is only one avenue of entrance to the liver for nox- 
ious agents, but no matter in what manner hepatic 
disease occurs there is usually a concomitant 
splenic enlargement. 

The syndrome called splenic anaemia, the terminal 
stage of which is known as Banti's disease, may be 
cured in many cases by removal of the spleen. 

Cases of stomach haemorrhage in which no other 
origin can be found should be carefully examined 
for evidence of splenic anaemia, as haemorrhage is one 
of the earliest symptoms in this condition. 

In Gaucher's disease, described by BriU and 
Mandelbaum, it is the author's experience that 
splenectomy in the early stages is followed by a cure. 

In haemolytic jaundice, which is of two types, 
that of Minkowski and that of Hayem and Widal, 
splenectomy gives the most brilliant results. 

In pernicious anaemia, remarkable improvement 
follows removal of the spleen if done before the 
spinal cord changes occur. 

Preliminary to splenectomy and often following 
it, blood transfusion is necessary in the majority 
of cases. The donor's blood should always be tested 
with that of the recipient for agglutination and 
haemolysis. P. M. Chase. 

Wahl, H. R., and Richardson, M. L.: A Study of 
the Lipin Content of a Case of Gaucher's 
Disease in an Infant. Arch. Int. Med., 1916, 
xvii, 238. 

The case on which this study is based was that of 
an infant eleven months of age, with a clinical picture 
which, in general, simulated Gaucher's disease. 
The spleen, liver, and lymph-nodes presented the 
usual changes, but the unusual feature of the case 
was the almost complete substitution of the medulla 
of both suprarenals by clusters of large pale vacuo- 
lated cells. The latter were also present in Peyer's 



patches, in the intestines, and in the thymus, besides 
involving the adventitia of some of the smaller 
vessels. The process was thus much more diffused 
than in any case hitherto described, and also the 
first one described in an infant, when the condition 
may be more diffused than when it occurs in adults. 
The author made an exhaustive study of the 
tissues of this case and an extensive review of the 
literature, the following conclusions being drawn: 

1. In Gaucher's disease the liver and the spleen 
show not only a marked increase in the lipin content, 
but also a serious alteration in normal relations of 
the lipins to each other. The fixed fats are greatly 
reduced, while the lipoids, such as lecithin and 
cholesterol, are greatly increased. In the case 
studied a lecithin-like body predominated, but a 
cholesterin compound may prevail in other cases. 

2. In Gaucher's disease, lipoid substances accu- 
mulate in the form of small droplets within the 
cytoplasm of the tissue-cells, resulting in the forma- 
tion and accumulation of the distinctive large pale 
cells so characteristic, histologically, of this disease. 

3. Gaucher's disease is due to a disturbance of 
lipoid and fat metabolism, resulting in the accumula- 
tion of lipoid sub3tances in the cytoplasm of the 
large pale cells that are mostly transformed reticulo- 
endothelial cells of the spleen, lymph-nodes, and 
bone-marrow, and the stellate cells of the liver. 
These cells have the physiologic property of dis- 
posing of the fats aijd lipoids, and comprise the 
endothelial Stoffwechselapparale. It is thus a system 
disease, but involves the haematopoietic organs 
only secondarily in that they are very rich in the 
reticulo-endothelial cells. 

4. Those organs that cotitain the reticulo- 
endothelial cells in large abundance (spleen, lymph- 
glands, bone-marrow, liver, stellate cells of Kupfer, 
etc.) show the most changes; but specific paren- 
chymal cells may absorb some of the lipoid in very 
advanced cases. 

5. Gaucher's disease belongs to the group of 
xanthelasmic conditions which are characterized 
by a more or less diffuse accumulation of lipoids in 
reticulo-endothelial or in fibroblastic cells in one or 
more organs. It represents a more diffuse and 
widespread involvement of the endothelial Stoff- 
wechselapparale than those cases of grosszellige 
Hyperplasie der MHz in diabetic lipoidaemia, with 
an underlying cause that is more deep-seated and 
inherent in the body economy. George E. Beilby. 



SURGERY OF THE EXTREMITIES 



DISEASES OF THE BONES, JOINTS, MUSCLES, 

TENDONS. CONDITIONS COMMONLY 

FOUND IN THE EXTREMITIES 

Ashhurst, A. P. G. : Multiple Cartilaginous Exosto- 
ses. Ann. Surg., Phila., 1916, Ixiii, 167. 

Ehrenfried has recently studied the clinical entity 
which goes under the name of multiple cartilaginous 



exostoses and prefers the name hereditary deform- 
ing chrondrodysplasia. He was able to find only 
about a dozen cases which had been reported in 
America, the greatest number of cases being reported 
from Germany and France. As the author has 
seen 11 cases within the last ten years, he con- 
cludes that the disease is not so rare as it seems, 
but that it has been overlooked or ignored. 



40 



INTERNATIONAL ABSTRACT OF SURGERY 



The underlying pathology is not the exostoses, 
but a chrondrodysplasia affecting especially the 
metaphyses of the long bones, though the bones of 
the pelvis, the clavicles, scapulae, and the vertebrae 
may be involved. The epiphysis is small or mis- 
shapen, the intermediary cartilage is narrow, irreg- 
ular, oblique, or zigzag, and sometimes prematurely 
ossified. Scattered along the ends of the shaft 
beneath the periosteum are clumps or nests of 
cartilage cells persisting uncalcified where they are 
left in the process of growth. Later, these groups 
may develop into the cartilaginous exostoses, which 
give the disease its name, but these are merely 
incidental. A malignant osteocartilaginous tumor 
may develop in one of these exostoses. Certain 
secondary characteristics usually are present, such 
as low stature due to the shortness of the limbs, 
particularly the lower. There often is a lack of 
growth of the ulna and pes valgus is frequent as the 
result of the lack of growth of the fibula. The 
disease is transmitted by both affected males and 
females and by unaffected females, but there is 
no evidence that it may be transmitted through 
unaffected males. 

The author reports ii cases which he has ob- 
served and two others from the service of Taylor 
which he did not have the opportunity to observe. 
In addition, he reports s cases which present no 
skeletal deformities and no evidence of being 
hereditary, but which are examples of some type 
of chondrodysplasia. Gate wood. 

Davidson, A. J.: Subungual Exostosis. Am. J. 

Orih. Surg., 1916, xiv, 150. 

The author observed 5 cases of painful enlarge- 
ment of the distal extremity of the great toe due to 
subungual exostosis. They were all males under 
30 years of age. No history of injury or infection 
could be obtained. The process requires from six 
to twenty-four months to develop sufficiently to 
cause the patient to seek advice. 

The etiology of exostoses in general may be 
summed up as: (i) those due to direct infection; 
(2) those due to direct trauma; (3) those associated 
with tendon or ligamentous strain, i. e., static. 

In the cases referred to by the author there was 
no history of infection of any kind, nor were there 
any inflammatory signs of either the matrix of the 
nail, the bone, or of the soft parts. Exostoses of 
the variety described could not be credited to any 
associated tendinous or ligamentous strain for the 
reason that no tendon or ligament is attached to 
the portion of bone from which the growth arises. 

By excluding these possible explanations it brings 
us to a consideration of trauma. The location of 
the exostosis is at a point which is frequently the 
site of trivial injuries and which is being constantly 
subjected to the continued pressure of the stiff box- 
ing of shoes. The usual atrophic conditions of the 
flexor muscles of the toes have the effect of increas- 
ing the power of the extensors, placing the toes in 
a position to bear the brunt of this shoe pressure. 



Regardless of the fact that no history of direct 
trauma could be obtained in any of his reported 
cases, Davidson thinks it is quite possible that sub- 
ungual exostoses are the result of trivial injuries or 
occur following the prolonged irritation of shoe 
pressure which may, or may not, be appreciated by 
the patient. Philip Lewin. 

Berry, J. M. : Retarded Ossification as an Etiologic 
Factor in Traumatic Arthritis and Epiphysitis. 

/. Am. M. Ass., 1916, Ixvi, 868. 

Three cases are reported in boys seven to ten years 
of age. In general the symptoms are the same: 
pain and swelling in the joints of the lower extrem- 
ity, a slight rise in temperature, and some limitation 
in motion. X-ray examination showed a retarda- 
tion in ossification in the areas involved and also 
in the wrists. 

The cases show that retarded ossification may be 
an etiologic factor in the production of traumatic 
arthritis and epiphysitis in children. The trauma 
in such cases consists in overstrain of the joints due 
to abnormal activity. The child may be leading 
the normal active life of a child of his own age, but 
anatomically he belongs to a type several years 
younger, and to avoid strain his activities should be 
correspondingly restricted. Cases of this character 
are probably quite common and are very apt to be 
overlooked or wrongly diagnosed. 

Edward L. Cornell. 

Fieux, G.: Treatment of Purulent Arthritis of 
the Knee by Arthrostomy or Marsupialization 
of the Synovial Sac (Le traitement des arthritis 
purulentes du genou par rarthrostomie ou marsup- 
ialisation de la synoviale). Presse mid., 1916, 
p. 107. 
Fieux affirms that in injuries of the knee-joint 
one of the factors which engenders rapidity of sup- 
purative diffusion is the difficulty of drainage or 
rather inefficacy of evacuation with drainage. 
According to Delore and Kocher arthrotomy for 
drainage is a blind method which is often in- 
suflScient. 

Fieux has observed in the wounded cases under 
his care that there was retention of pus in the serous 
cavity in spite of the presence of several large 
permeable drains. From close observation he 
came to the conclusion that it was the drain itself 
that formed the obstacle to drainage. He therefore 
replaced arthrotomy with drainage by arthostomy, 
creating one or more articular mouths kept wide 
open which allowed the continuous evacuation of 
the infected joint contents without the aid of any 
tube. He gives the details of seven cases treated 
in this manner. 

This method of evacuation of the knee-joint in no 
way obviates the indications for resection of the 
knee which have recently been formulated by Tufl&er 
and others; but it is incontestable that the more 
quickly and better septic products are evacuated 
from the synovial spaces, the less the indications are 
for resection. This is why he thinks that arthros- 



GENERAL SURGERY — SURGERY OF THE EXTREMITIES 



41 



tomy is superior to arthrotomy incisions with drain- 
age tubes. W. A. Brennan. 

Dunlop, J. : A Deposit in the Supraspinatus Muscle 
Simulating Subacromial Bursitis. Am. J. 

Orth. Surg., 1916, xiv, 102. 

The author reports a case of a large deposit 
about the tendon of the supraspinatus, as well as a 
considerable deposit in the belly of the muscle 
demonstrated by stereoroentgenograms. 

The treatment instituted was a plaster-of-Paris 
cast, such as is used in the abduction position for 
fracture of the neck of the humerus. This was ap- 
plied under nitrous-oxide anaesthesia. After ten 
days the cast was removed and the support and 
position were gradually done away with. Hot air 
bakes are useful in such cases in relieving pain and 
hastening the return of normal motion. 

Philip Lewin. 

FRACTURES AND DISLOCATIONS 

Hitzrot, J. M., and Boiling, R. W.: Fractures of 
the Neck of the Scapula. Ann. Surg., Phila., 
1916, Ixiii, 215. 

Fractures of the neck of the scapula with or 
without involvement of the glenoid fossa, while 
not common, have been found to be of more frequent 
occurrence since the advent of the X-ray. These 
fractures fall into the following groups: 

1. Fractures of the surgical neck of the scapula. 

2. Fractures of the lower half of the neck of the 
scapula. 

3. Fractures of the neck of the scapula beginning 
at the notch and extending downward through 
the base of the coracoid process to the glenoid 
fossa. 

4. Fractures of the anatomical neck. 

5. Stellate fractures of the glenoid fossa of the 
scapula. 

6. Fractures of the rim of the glenoid, with or 
without fissures running into the neck. This 
type is frequent in dislocation of the shoulder, and 
as they occur as complicating injuries of disloca- 
tions, the authors have not included them in their 
review of the literature. 

There is no authentic case of the fourth type 
recorded in the literature. 

The authors report nine cases and the results of 
some experiments upon the cadaver. From their 
observations they conclude that the description of 
the deformity resulting from fracture of the region 
of the neck of the scapula as ordinarily given is not 
correct and that the fracture in this region may occur 
without any recognizable deformity. They believe 
that the clinical manifestations of the fracture are 
insufl&cient to make a positive diagnosis, and that 
the X-ray is an essential factor in the diagnosis. 
The immobilization of the arm by a Velpeau or 
similar bandage is all that is necessary in the way 
of treatment, and manipulative efforts have no 
effect upon the displacement which occurs at the 
line of fracture. By massage, baking, and careful 



after-treatment practically perfect functional re- 
sults will be obtained. Should a type of fracture 
occur in which the displacement actually promises 
bad results, the fracture could best be treated openly 
by approaching it from behind and the glenoid 
fragment pried into position, with correction of the 
coincident injuries by appropriate methods of 
repair of the ligaments, etc. Including the cases 
reported by the authors, there are only about 
forty cases in the literature in which the diagnosis 
has been confirmed by X-ray or by autopsy. 

Gatewood, 

Roberts, J. B.: The Artificial Periosteum for 
Fixation of Shaft Fractures. Ann. Surg., Phila., 
1916, Ixiii, 182. 

Although the author has not changed his views in 
regard to the closed method of treating the great 
majority of fractures, he advocates the use of an 
artificial periosteum in certain cases in which there 
are definite indications for an open operation. 
Instead of the woven catgut rugs suggested by 
D. C. Straus, the author suggests the use of an 
autogenous graft of fascia. He states that the use 
of fascia may be varied for the various types of 
fracture; for instance, two narrow splints may be 
wrapped about the bone a considerable distance 
from each other in case of a very oblique fracture, 
or a wider band used where the fracture is more 
transverse. The object of the fascial tube is to make 
an artificial periosteum which would act as an 
absorbable support for shaft fractures. The author 
has not demonstrated the efficiency of such a method 
of fracture treatment either by experimental work 
or by actual use in suitable cases. Gatewood. 

McGlannan, A.: Fracture of the Neck of the 
Femur; a Study of the Treatment and End- 
Results of 55 Cases. Surg., Gynec. & ObsL, 1916, 
xxii, 287. 

The author reports 55 cases of fracture of the 
neck of the femur that have come under his per- 
sonal observation in the past eight years. In this 
series 36 recent fractures and 7 old fractures were 
treated, and 1 2 patients were not treated. 

In all cases, full abduction, with downward trac- 
tion and inward rotation, was the position obtained 
in the reduction of the fracture. The full abduction 
was assured by fixation of the pelvis by abducting 
the sound leg, and the inward rotation by lifting the 
trochanter forward. Impaction was separated in 
6 cases, and in the seventh was not disturbed because 
the impaction occurred with abduction of the thigh. 
This is an unique observation. 

Various forms of fixation were used, from firm 
plaster-of-Paris cast to loose tying out of the thighs. 
Direct extension by ice-tongs was used in 3 handi- 
capped patients, one of whom died. Nailing the 
fracture was done twice. 

For the old cases, bone-graft was used once, nail- 
ing twice, removal of head once, subtrochanteric 
osteotomy twice, freshening fragments once. 



42 



INTERNATIONAL ABSTRACT OF SURGERY 



Of the recent cases four died and in one the frac- . 
ture failed to unite. One of the old cases resulted 
fatally and the patient still walks on crutches 7 
years after treatment. 

Treatment was refused by 2 young adults, with 
vicious union. Ten patients were not treated on 
account of feebleness and circulatory, pulmonary, 
renal, or nervous symptoms. Two are living 
several years after the injury, aged 88 and 90 years, 
respectively. Delirium tremens and evidence of 
drug addiction or uraemic manifestations make the 
prognosis grave. Loss of control of bladder or 
rectum seems to indicate an inability to stand fixa- 
tion. The effect of the healed fracture on earning 
capacity is noted in 10 cases, the average loss being 
15 per cent, after a period of disability lasting from 
6 months to i year and 3 months, with an average 
close to I year. The occupation of these patients 
included hotel manager, restaurateur, farmer, 
housekeeper, seamstress, laborer, tailor, motormen, 
and market driver. 

SURGERY OF THE BONES, JOINTS, ETC. 

Burckhardt, H., and Landois, F.: Experiences in 
the Treatment of Infected Joints in War 

(Erfahrungen ueber die Behandlung inficierten 

Gelenke im Kriege). Beitr. z. klin. Chir., 191 6, 

xcviii, 358. 

The authors have reported their methods in a 

previous communication but were then unable to 

report on the end-results. They now report these 



end-results and are able to state their conclusions on 
a more definite basis. This study is a contribution 
to the question whether resection of a joint is justi- 
fiable in war or not. 

In all severe cases of joint infection, the indica- 
tions alone must decide whether resection or ampu- 
tation is to be resorted to. Resection is generally 
done (i) in the field hospital as part of the immediate 
treatment of the wound; (2) later on, on some vital 
indication when amputation is avoided; (3) after 
a longer period when it is thought to effect healing 
of a chronic joint suppuration. 

The most important and the most frequently 
observed cases of joint infection are those of the 
knee-joint, which when badly infected are almost 
as important as hip-joint infections as regards 
relation to life and function. If the fissures extend 
well into the tibia amputation is the best method, 
but if amputation is not done, then a radical resec- 
tion with ablation of the bone ends is preferable to 
simpler procedures. 

Regarding individual joints: resection in the case 
of the hand-, foot-, and elbow-joints gives good 
results. In the case of the knee-joint resection is 
indicated if the general state is good and there 
is only a moderate amount of bone destruction and 
if a sufficiently long treatment of the patient in 
one place can be assured. But the general results 
are poor and although the limb is preserved pseudar- 
throsis usually results. Nevertheless, resection 
or at least some simpler operation should be tried 




Fig. I. Cuneiform osteotomy, showing lines of section 
at A and B. 

Fig. 2. Wedge removed in cuneiform osteotomy. 

Fig. 3. Bone straightened after cuneiform osteotomy, 
showing transverse joint at A. 

Fig. 4. New operation; lines of section at A ,B, C, D. 

Fig. 5. Fragments removed in new operation. 



Fig. 6. Shape of bone ends after removal of fragments. 

Fig. 7. Rearrangement of removed fragments. Note 
that combined they correspond exactly in size and shape 
to the wedge shown in Fig. 2. 

Fig. 8. Bone straightened after new operation, showing 
overlapping joint at A. Note that the length of the bone 
is exactly the same as in Fig. 3. (HofiFman.) 



GENERAL SURGERY — SURGERY OF THE EXTREMITIES 



43 



when the above conditions are present. If they are 
not, then amputation must be done to save the pa- 
tient's life. 

In the shoulder- joint resection gives better results. 
In infected hip-joints, the casualties are very great 
and resection very rarely saves the life of the patient. 

W. A. Brennan. 

Hoffman, P. : An Overlapping Joint as a Substitute 
for Cuneiform Osteotomy. Am. J. Orth. Surg., 
1916, xiv. 96. 

The author devised an operation that substitutes 
for the simple transverse joint made in the cunei- 
form section, an overlapping one that is less liable 
to displacement. There is an underlying simple 
general plan that involves two linear cuts and the 
removal of two corners of bone, no matter what the 
degree of angularity. 

The first cut is perpendicular to the long axis of 
one of the arms of the deformed bone, on a level with 
the apex of the angle on the concave side of the bend. 
This divides the bone into a longer and a shorter 
segment. 

The second cut is made perpendicular to the long 
axis of the longer segment, on a plane parallel with, 
but distal to, the cut that would have been made in 
a cuneiform osteotomy. The more distal this plane, 
the longer will be the overlapping tongue of the re- 
sulting joint. 

Next, the end of the longer segment is turned 
out through the skin incision and a corner is re- 
moved from its deeper side. The longitudinal cut 
should be parallel to the long axis of the segment 
and should divide the bone equally; the transverse cut 
should be on a level with what was the apex of the 



angle on the concave side of the deformity. This 
leaves a projecting tongue, half the thickness of the 
bone on the superficial side of the end of the longer 
segment. Next, a corner is cut from the superficial 
side of the end of the shorter segment which leaves 
a tongue projecting from the end on its deep side. 
The two corners should fit each other. The ac- 
companying diagrams illustrate the steps. 

No bone-suture is necessary. All the bone cuts 
are made with an ordinary flat saw. The combined 
fragments correspond in size and shape to that re- 
moved by cuneiform osteotomy and the length 
of the bone is exactly the same as after that op- 
eration. PmLip Lewin. 

Kane, E. O. : Preliminary Report on Device for 
Intramedullary Fracture Splinting, hiternat. 
J. Surg., 1916, xxix, 33. 

An expanding scroll cylinder of thin steel is 
recommended to replace the short ivory or bone 
peg for intramedullary splinting of long bones. 
After clearing the medullary cavity by curette or 
drill the length of the splint at one extremity and 
half its length at the other the cylinder (secured 
from expansion by a silk cord firmly tied about the 
middle) is thrust its full length within the longer 
excavation. The broken ends of bone are approxi- 
mated and the cord pulled firmly. The splint 
slides half its length from its bed into the opposing 
cavity. The cord is then cut free from the cylinder, 
the scroll expands, filling the cavity tightly and 
holding the fracture immovable. 

This method provides sufficient space without 
traction or angulation of the opposing fragments, 
yet a splint fully twice the length of the usual peg 




Fig. 9. Tracing of radiography, showing cuts, A and B, 
that would have been necessary for a cuneiform osteotomy, 
and the resulting wedge fragment. 

Fig. 10 Tracing of radiograph, showing cuts, A, B, C, 
D, actually made in the author's operation and the resulting 
fragments removed. 



Fig. II. Rearrangement of removed fragments. Note 
that combined they correspond in size and shape to the 
wedge shown in Fig. 9. 

Fig. 12. Bone straightened after operation, showing 
overlapping joint at .\. (HofiFman.) 



44 



INTERNATIONAL ABSTRACT OF SURGERY 



can be inserted; consequently a very oblique fracture 
is held as accurately in position as if it were trans- 
verse. The tissues are disturbed but slightly, the 
technique is simple, the procedure rapid. The 
hollow cylinder permits new medullary and bone 
formation, and being of the thinness of tissue paper 
(two-thousandths of an inch in thickness) the steel 
can corrode away. 

Ghaput: Resection of Almost the Whole of the 
Humerus for Fistulous Osteomyelitis, Fol- 
lowed by Osseous Reproduction Without 
Shortening and with the Production of a New 

Humeral Head (Resection de la presque totalite 
de I'humerus pour osteomyelite fistuleuse, suivie 
de reproduction osseuse sans raccourcissement avec 
production d'une t^te hum6rale nouvelle). Bull, 
et mem Soc. de chir. de Par., 1916, xlii, 433. 

The author reports a case of multifistulous osteo- 
myelitis in a boy of 16. In February, 1914, Chaput 
resected from 12 to 15 cm. of the lower part of the 
humerus. Later on in May, 1914, owing to the 
development of a fistula the upper third of the 
humerus comprising the articular extremity was 
ablated. Cicatrization occurred in from two to 
three months; the bone reproduced and united with 
the new bone of the lower region. 

This reproduction of almost the entire humerus 
Chaput explains as being due to the preservation 
of the periosteum and the youth of the patient. 
Up to the twentieth year the regenerative power of 
periosteum is very active. After thirty grafts are 
indispensable. 

The continued use of extension in this case pre- 
vented shortening. The reproduction of the humeral 
head is very interesting. It has only been possible 
owing to the abundant formation of bone which has 
been facilitated by movement. W. A. Brennan. 

Albee, F. H. : A Statistical Study of 539 Cases of 
Pott's Disease Treated by Bone-Graft. Am. 

J. Orth. Surg., 1916, xiv, 134. 

With the object of securing a report of results ob- 
tained by others with the bone-graft treatment of 
Pott's disease, a large number of printed questions 
were sent to surgeons in this and foreign countries 
who had performed this operation. 

Thirty-three surgeons reported a total of 299 
results, in 229 of which the disease was pronounced 
arrested; in 59 the condition was improved. Of the 
299 patients 12 died, 4 of these fatalities being re- 
ported as due to shock. The remaining 8 cases 
died four months or longer after the operation, either 
from complications or from intercurrent diseases. 
In 5 of these cases the symptoms from spinal dis- 
ease were entirely controlled. In 3 of the 4 cases in 
which death was due to shock, the chisel and mallet 
were used to obtain the grafts. 

Of the 33 surgeons 16 reported 100 per cent 
of the cases as disease arrested; 10 reported that they 
did not use plaster jackets or spinal support be- 
yond the period of immediate post-operative recum- 



bency: 9 reported 100 per cent of cases arrested and 
one secured 88 per cent of good results. 

Of the author's personal cases only those that have 
been operated upon one year or longer are included 
in this report. There are 198 of these; in 184 the 
disease was arrested, in 2 there was improvement. 
To date 1 2 died, 6 of these 1 2 were entirely relieved 
of their Pott's disease symptoms and died of some 
intercurrent disease. 

One case died of an unknown cause the day after 
operation, one died of acetonuria on the fourth day, 
one from status lymphaticus, one died two years 
after operation from suppurative meningitis follow- 
ing a skull injury. Autopsy showed complete cure 
of the tuberculous spine. One died of pneumonia 
one week after operation. Others died of amyloid 
degeneration of the viscera, tuberculosis of the lung, 
and an acute abdominal condition. Only 3 of the 
539 cases have died of tuberculous meningitis. 
In no case has there been any trouble with the tibia 
from which the graft was removed. 

The ages of the patients varied from 20 months 
to 65 years. Of the total 539 cases, the disease 
was arrested in 460; the condition was improved in 
59; in 20 unimproved. There were 9 deaths after 
operation. In 6 instances death occurred long after 
operation and after all spinal symptoms were entire- 
ly relieved. 

The author concludes his interesting paper by 
stating that every diagnosis of Pott's disease should 
be confirmed by an X-ray examination which should 
include an anteroposterior view, as well as a lateral 
or an oblique lateral. The disintegration and 
crushing of the vertebral bodies should always be 
demonstrated before advising the operation. This 
is necessary not only to confirm the diagnosis but it 
is most imperative to determine the number and the 
particular vertebrae involved so that the graft can 
be correctly placed. Philip Lewin. 

McWilliams, C. A.: Homoplastic Transplantation 
of a Boiled Segment of a Radius. Ann. Surg., 
Phila., 1916, Ixiii, 185. 

Berwer, in January, 191 2, transplanted a radius 
from a suicide into the arm of a patient 
operated upon a few days previously for sarcoma of 
the radius, in whom it had been found necessary to 
remove the lower two and three-eighths inches of 
the bone. The transplant was boiled for an hour 
and kept in normal salt solution for four days. 
Primary union occurred without any subsequent 
discharge. 

The author reports the Brewer case as an example 
of a homoplastic transplant which has been at least 
partially successful. From the present roentgen- 
ogram it appears that the portion of the graft 
nearest to the living bone has regenerated complete- 
ly or has been entirely substituted; that that farther 
away has been only replaced, while the free end was 
entirely absorbed. The author believes that an 
autogenous transplant would have given better 
results. He concludes that dead bone merely acts 



GENERAL SURGERY — SURGERY OF THE EXTREMITIES 



45 



as a conductor, and that if homoplastic transplants 
are employed at all they should be taken from 
living individuals and transplanted with the peri- 
osteum. The success of a homoplastic transplant 
will depend upon the serological relations between 
the individual from whom the graft is taken and 
the one into whom it is to be grafted. The case is 
of interest on account of the extreme rarity of 
reports of successful homoplastic transplantation. 
In conclusion, the author gives a summary of the 
cases of living and dead homoplastic bone trans- 
plantations in the literature, between thirty and 
forty cases in all. Gatewood. 

Freiberg, A. H.: Tendon-Transplantation in 
Infantile Paralysis. Lancet-din., 1916, cxv, 179. 

Tendon-transplantation is a measure of utmost 
value in paralysis following anterior poliomyelitis, 
but the end-results have not yet shown unqualified 
success. Primary results have been attractive, 
but the corrections have often been only temporary. 
The failures have been due to various impractical 
mechanical conditions. Stoffel's prerequisites for 
successful transplantation are: (i) The transplant 
must bear a fairly close morphological and func- 
tional relationship to the muscle whose function it is 
to supplant. (2) The transplant must be fastened 
to its new point of insertion under physiological 
tension only. (3) The transplanted muscle must not 
b6 used to hold the limb in a corrected position. 

Freiberg describes his operation for paralytic 
equinovalgus. He divides the Achilles tendon, and 
taking the extensor longus hallucis, passes it through 
the same compartment in the annular ligament 
with the tibialis anticus and sews it to the periosteum 
in company with the insertion of the tibialis anticus. 
Thus the direction and insertion of the two muscles 
are practically identical. Freiberg emphasizes the 
necessity for direct and simple operative plans, and 
condemns the attempts at converting flexors into 
extensors, etc. 

In the treatment of infantile paralysis during the 
first year, mechanical support must be used to pro- 
tect the paralyzed muscles from overstretching, 
also muscle-training, massage, and local heat should 
be used, but by no means any form of electricity. 
Only after a long period should any operative pro- 
cedure be considered. R. G. P.\ck.\rd. 

Ryerson, E. W. : Deformities Due to Infantile Par- 
alysis; Operative Treatment. Am. J. Orth. Surg., 
1916, xiv, 59. 

While it is undoubtedly true that some cases are 
best treated by apparatus it is especially eflfective in 
flail knee-joints where both the flexors and extensors 
are paralyzed, and the best treatment is a brace with 
a lock-joint. If a single hip-joint is flail arthrodesis 
is best ; if both hips are flail apparatus is a necessity. 
With these exceptions practically all other leg and 
foot deformities and weaknesses can be treated 
better by operation than by apparatus. 



The practice of repeated tenotomy and brace- 
wearing is to be strongly condemned. Where any 
reasonable operative procedure can free the patient 
from the need of apparatus, it should be used. 
No radical operation should be performed until at 
least two years have elapsed after the attack of 
anterior poliomyelitis. During this time an attempt 
should be made to favor the return of power to all 
unparalyzed muscle-fibers. Deformity should be 
prevented, if possible, by apparatus, such as braces 
or plaster-of-Paris splints. The patient should be 
compelled to use the weakened muscles. Electricity, 
massage, and hot and cold water should be used to 
stimulate the nutrition of the muscles. If at the 
end of two years the condition is not satisfactory, 
a thorough anatomical examination should be made 
to determine what can be done by operation. 

For drop-foot Ryerson recommends either split- 
ting or lengthening the tendo achillis, if short, by 
Bayer's tenotomy. If the extensors of the toes are 
active they may be fastened to the metatarsal 
bases, preferably by passing each through a hole 
drilled in its respective bone or by splitting the 
periosteum, gouging out a groove in the bone, and 
sewing the tendon into the groove beneath the perios- 
teum. 

For paralysis of toe extensors as well as of the 
tibialis anticus one or both of the peronei may be 
displaced forward in front of the malleolus and sewed 
to the scaphoid or middle cuneiform. If the tibialis 
posticus be active, it may also be displaced forward, 
like the peronei, and may be needed to check the 
tendency to valgus. In simple drop-foot as well as 
in varus or valgus deformity, the astragaloscaphoid 
arthrodesis should always be performed by firmly 
sewing the bones with several bichloride silk or 
kangaroo tendon sutures. In 15 cases where the 
author has split the gastrocnemius and passed one 
half of it forward to act as a dorsiflexor of the foot, 
he failed to obtain active function although it acted 
as a good check-ligament. 

He recommends Gallie's operation to control the 
equinus but in his experience of 25 cases it repeatedly 
failed to prevent lateral deviation. He says it 
should invariably be supplemented by arthrodesis 
of the astrogaloscaphoid joint or by taking a strip 
of periosteum and bone from the tibia and implant- 
ing it in a groove cut along the inner side of the 
astragalus, the internal cuneiform, and the first 
metatarsal bones. 

Heavy bichloride silk hgament from a hole drilled 
in the tibia running down under the annular liga- 
ment to the inner and outer metatarsal bones gives 
excellent results where there is no lateral deformity. 
It should be combined with astragaloscaphoid 
arthrodesis. 

For pes calcaneus. Whitman's operation is the 
best. For paralysis of the extensor quadratus of the 
thigh the author strongly recommends the trans- 
plantation of a healthy biceps and semitendinosus 
forward into the patella. In contractures of the 
tensor fascia lata and other structures around the 



46 



INTERNATIONAL ABSTRACT OF SURGERY 



hip, the subperiosteal method of Souttar is excel- 
lent. Philip Lewin. 



ORTHOPEDICS IN GENERAL 

Corner, E. M.: Deformities of the Feet. Clin. J., 
1916, xlv, 93. 

The author discusses various deformities of the feet 
from the standpoint of the normal positions a.nd 
movements of the foot. Deformities are variations 
from these normal conditions. The foot at rest 
normally is in a position of moderate calcaneus while 
the active foot is in a position of talipes equinus. 
At the ankle-joint the movements of dorsal and 
plantar flexion of the foot occur, at the midtarsal 
joint abduction and adduction occur. Pes planus 
is a deformity of abduction and pes cavus is one of 
adduction. Abduction causes a depression of the 
normal arch of the foot but paradoxical as it may 
seem some persons have all the symptoms of flatness 
of the foot but nevertheless have an arched instep. 
By means of diagrams he shows the occurrence of 
callosities on the soles of the feet which are caused 
by the assumption of these varied positions, thus 
the abducted foot has its typical localized callosities, 
the adducted its own, etc. The deformities of the 
active foot, talipes equinus and pes cavus, usually 
cause few symptoms, but the deformities of the in- 
active foot, talipes calcaneus and pes planus, re- 
quire treatment. 

At the metatarsophalangeal joints, he describes 
the deformity of hallux rigidus which in the active 
position develops into hallux extensus and in the 
inactive position, into hallux flexus. These are 
caused by bosses of bone developing on the dorsal or 
under surfaces of the head of the matatarsal bone. 
If they grow out laterally they produce hallux valgus 
or hallux varus depending upon the side they grow 
upon. The treatment is the operative removal of 
these bony outgrowths, with the wearing of prop- 
erly shaped boots. R. S. Bromer. 

Lovett, R. W.: The Superstition of Fiat-Foot. 

Pediatrics, 1916, xxviii, 16. 

From a study of the feet of 800 nurses the author 
concludes that the troubles ordinarily described 
as "flat-foot," "pronated-foot," and "weak-foot" 
are not due to any particular type or structure of 
foot. A foot with a high arch was found to be 
slightly less enduring than the low-arch type. He 
concluded that the trouble was due to muscular 
strain. Frequently the arch of the sole of the boot 
is not so high as the arch of the foot, and this is 
apt to cause strain. 

Painful rigid flat-foot should be treated by 
manipulation under ether or by operation. Painful 
flexible flat-foot or foot strain will require the temp- 
orary use of a support. The arch of the sole of the 
shoe should also be raised sufficiently to support 
the arch of the foot. I. Bauman. 



Schmidt, M.: Congenital and Especially Bilateral 
Elevation of the Scapula (Ueber den angeborenen 
insbesondere doppelseitigen Schulterblatthoch- 
stand). Ztschr. f. orthop. Chir., 1915, xxxv, Mar. 

There are 16 cases in the literature of bilateral 
elevation of the scapula. Various theories have 
been off^ered as to the cause of the deformity: lack 
of amnios fluid, exostoses, muscular defect, intra- 
uterine poliomyelitis, and malformation of the 
scapula, also the arrest of the normal descensus of 
the shoulder-blade. 

The technique of the operation which was per- 
formed by Vulpius is as follows: Incision along the 
spine of the scapula directly to the bone; elevation 
of the periosteum and entire resection of the bony 
part of the fossa supraspinata. This part of the 
scapula appears to be bent forward over the shoul- 
der. The median part of the scapula and an exosto- 
sis reaching from the median border into the depth 
are also resected. Then a subcutaneous tenotomy 
of the tendons of the posterior wall of the axilla 
is performed. A plaster-of-Paris dressing in abduc- 
tion is applied and left on for four weeks, followed 
by massage. Orthopedic gymnastics are of prime' 
importance in the after-treatment of the deformity. 
In the case described, the elevation of the arm was 
increased from 85 to 128 degrees. A. Steindler. 

O'Reilly, A. : Results of Non-operative Treatment 
of Infantile Paralysis. Am. J. Orlh. Surg., 1916, 
xiv, 143. 

The author's paper is based on a study of the cases 
of infantile paralysis treated at the out-patient clinic 
of the St. Louis Children's Hospital and the Washing- 
ton University Medical School. The majority of 
cases seen were paralyses of the lower extremity. 
The muscles are put in equilibrium and all strain is 
removed from the weak or paralyzed muscles. In 
the majority of cases a brace is applied. Originally 
the brace was attached to the shoe. For the past 
two years sandals have been used. Any deformity 
due t() contractures which does not yield to stretch- 
ing is corrected by tenotomies. 

The patients come to the clinic three days a week 
for massage and muscle training, and the mothers are 
instructed how to massage them on the other days. 

From an analysis of 114 cases treated the author 
concludes that it is very difficult to treat infantile 
paralysis non-operatively in an out-patient clinic 
owing to the difficulty of inducing the patient to 
attend regularly for any length of time. 

From 40 to 45 per cent of the cases show some im- 
provement when treated by braces and this percent- 
age is not materially increased by the use of massage. 
Improvement in all cases in which it was used was 
not great, and recovery of muscle power in stretched 
and exhausted muscles seems to be slight. In the 
majority of cases no improvement took place after 
six months especially in the more severe cases. He 
believes that one is safe in operating on any case of 
infantile paralysis after the first year and that it 
should be done in suitable cases. Philip Lewin. 



GENERAL SURGERY — SURGERY OF THE SPINAL COLUMN AND CORD 47 



SURGERY OF THE SPINAL COLUMN AND CORD 



Gates, B. B.: Spina Bifida. Boston M. &-. 5 /., 

191 5, clxxiv, 420. 

The author reports 9 cases of spina bifida coming 
under his care, making in all 16 cases which he 
has treated. The ages varied from 21 days to 12 
years, though with the exception of 2, the ages 
averaged about eight weeks. The history of each is 
given in full. Of the author's 16 cases, 10 survived 
beyond a post-operative period of three months. 
He beUeves that the age of the patient is not such 
an important factor in determining the personal 
equation as the physical condition, and believes 
the surgeon may with a clear conscience urge the 
lesser of two evils, operation under the most favor- 
able conditions, rather than rupture with risk of 
infection and meningitis. Emil C. Robitshek. 

Rugh, J. T. : Bone-Grafting for Spinal Conditions; 
Report of Forty Cases. Am. J. Orth. Surg., 

1916, xiv, 71. 

The author claims six advantages for the bone- 
grafting operation, viz.: 

1. It accomplishes fixation in less than a year, in 
marked contrast to the four to ten years required 
by other methods. 

2. Under this fixation treatment, nature will more 
rapidly fill in or solidify the diseased area. 

3. An abscess formed or in the process of forma- 
tion will usually disappear without tapping or 
opening. 

4. Very low mortality. 

5. Manipulations are all done in normal healthy 
tissues in the vast majority of cases. 

6. The economic advantage which in the case of 
the wage earner makes him an independent member 
of the community within a year. 

In his experience with forty cases Rugh has found 
no disadvantages that can be attributed to the 
operation per se. 

He beUeves that the operative fixation of the 
spine is the treatment of choice, for spinal caries 
and certain other conditions, and especially so in 
cases past 12 or 14 years of age. He reports a series 
of forty operations with 74.3 per cent of excellent 
results, and Lange's requirements were fulfilled 
in that he "placed the brace under the skin and 
shortened the time of efficient recovery." 

PmLip Lewin. 

Claude, H., and L'Hermitte, J.: Anatomo-clinical 
Study of a Case of Total Section of the Spinal 
Cord (£tude anatomo-clinique d'un cas de section 
totale de la moelle). Bull et mem. Soc. med. d. 
hop. de Par., 1916, xxxii, 476. 

The authors consider that the case now reported 
upon by them presents a double interest inasmuch 
as it shows unusual clinical expressions of total 
section of the spinal cord, and that it permits of 



localizing the origin of certain reflexes which up to 
now have been matters of discussion. 

There is no certain symptom which allows the 
diagnosis of total section of the spinal cord, while 
some patients exhibit all the classical symptoms, 
yet anatomical examination proves that the medul- 
lary axis is preserved in its continuity. The case 
now presented, while showing unusual features, al- 
lows this diagnosis and also indicates how certain 
traits must be interpreted. 

The patient was a soldier who in consequence of 
injuries presented a vertebral fracture with very 
marked gibbosity in the region of the eighth spinal 
dorsal apophysis. Examination 19 days after the 
injury showed complete anaesthesia as far as the 
eleventh dorsal root ; complete abolition of the rotu- 
lian and achillean reflexes and of the lower abdominal 
reflexes; inversion of the plantar cutaneous reflex; 
absolute retention of urine; relaxation of the anal 
sphincter, etc. Forty-eight days after the injury 
there was a reappearance of the tendon reflexes 
which were exaggerated. Eight days later, defense 
movements of the lower limbs were noted and within 
a few weeks more there were automatic movements 
of the limbs. These movements were preserved 
up to the time of the patient's death which occurred 
four and one-half months after the injury. 

The reappearance of the automatic movements 
suggested a very severe compression rather than a 
total section of the cord, and surgical interference 
was suggested but refused by the patient. 

Autopsy clearly showed that there was a fracture 
of the dorsal vertebra; the spinal cord was not only 
compressed but literally crushed, this crushing 
corresponding to a total section. There was a 
complete isolation of the lumbar and dorsal cord as 
well as of the encephalic connections. 

The authors observe that their findings show that 
while in the majority of cases of total section there 
is a flaccid paraplegia with muscular hypotonus and 
abolition of tendon reflexes; yet sometimes after 
such symptoms there may be clinically a restora- 
tion of certain tendon reflexes, even an exaggeration 
of them, and an increase of reflexes of defense and 
of spontaneous movement. The phenomena dis- 
played by the author's patient was in contradiction 
to the law of Jackson-Bastian, according to which 
every complete section of the cord is accompanied 
by an absolute anaesthesia and a flaccid paraplegia 
with definite abolition of the tendinous reflexes. 

The authors account for the exaggerated tendon 
reflexes by the compression of the lower trunk of the 
cord, owing to the presence of an anterior dura 
mater nodule. This slight compression, by increas- 
ing the dynamism of the gray matter, seems to be 
the most valid cause of the tendinous suprareflec- 
tivity. As regards the defense movements the au- 
thors agree with Marie, Foix, and Dejerine that they 
are due to medullary automatism. 



48 



INTERNATIONAL ABSTRACT OF SURGERY 



In further considering the phenomena observed 
in their case, the authors observe that the preserva- 
tion of the spinal vessels assured the lower segment 
a better nutrition than in cases where the isolated 
segment is deprived of all vascular connection with 
the encephalic segment. Moreover in their case 
the circulation of tjie cephalorachidian liquid was 
not sensibly disturbed, and as a consequence 
there was no interference with the osmotic phenom- 
ena of the nerve-cells through the pericellular and 
perivascular lymphatic spaces. W. A. Brennan. 

Jonas, A. F. : Dislocation of the First Cervical 
Vertebra Produced by Manipulation. Tr. Am. 

Surg. Ass., Washington, 1916, May. 

The author reports one case which is made the 
subject of his paper. The patient was a farmer who 
appeared for examination in August, 191 5, with his 
head dropped forward, face partly turned toward 
the right side, and his chin resting on his sternum. 
His eyebrows were highly elevated. His neck 
seemed to be fixed, for he did not make the slightest 
cervical rotation. A lateral view disclosed the upper 
end of the cervical region projecting sharply back- 
ward on the occiput. His appearance suggested a 
destructive cervical spondylitis or an occipito- 
cervical neoplasm. He spoke with difficulty for he 
could separate his jaws only to a very limited extent. 

He stated that he had not been able to turn nor 
raise his head for more than a year and that his 
condition was due to manipulations received at 
the hands of an osteopath while under treatment 
for " generalized rheumatism." He had been placed on 
his back on an operating table and the treatment 
was begun with vigorous and forcible rotations of 
the head. The operator, standing at the head of the 
table, had grasped the patient's head with both 
hands, one resting on either side of it, two fingers, 
the index and middle, beneath each horizontal 
maxillary ramus, and while being held thus, his 
head was "twisted" from side to side by extreme 
and forcible rotations, causing great pain. He 
suddenly felt and heard a loud painful snap in the 
back of his neck at the base of the skull and his 
head became fixed in the position described and had 
so remained. He stated that his condition had 
become unbearable on account of the pain in the 
back of the neck and occiput and his inability to 
separate his jaws enough to enable him to eat or 
speak with freedom. He had had an almost con- 
stant vertical headache as well as pain in the neck 
since the accident. 

On examination, any attempt to rotate his head 
caused a marked muscular spasm involving all the 
cervical rnuscles, especially the trapezii and sterno- 
cleido mastoids. An osseous projection was not only 
palpable but distinctly visible in the occipitocervical 
space. This appeared to be a spinous process be- 
longing either to the first or second cervical verte- 
bra. The tip of the spine appeared to deviate to the 
left of the median line. It was tender on pressure 
and caused the patient to flinch decidedly. In- 



spection and palpation of the pharynx disclosed 
an irregularity and tenderness at the nasopharyn- 
geal junction. 

It was evident that it was a case of luxated cervical 
vertebra, probably the first one, the atlas. There 
had been no cord pressure symptoms, except for an 
occasional tingling of short duration in both arms 
and hands. There had been no motor disturbances; 
all reflexes were normal; and a careful search for 
sensory changes was negative. A skiagram pre- 
senting a lateral view of the cervical spine revealed 
a retrodisplacement of the atlas. The space between 
the posterior margin of the foramen magnum and the 
first cervical spine was clearly increased. The con- 
dition was not clear on first inspection owing to the 
fact that the spine of the second cervical vertebra 
is much larger and longer under normal conditions 
than that of the first, the latter usually being absent 
or rudimentary. Further, a dislocation at this 
point without a fracture of a transverse or articular 
process of the axis and an absence of cord lesion 
is improbable. Therefore, it was evident that there 
was a slipping forward of the head on the atlas 
involving the occipito-atlantal articulation. The 
occipital condyle, probably the left one, had slipped 
forward so that it rested in front of the margin of 
the left superior articular surface of the atlas, 
causing a fixed rotary anterolateral flexion of the 
head. The patient was informed of his condition 
and advised to return to the osteopath as this 
class of practitioners consider themselves super- 
bone-setters. He declined in as vigorous Eng- 
lish as his set jaws would permit and insisted 
that the author make a manual reduction. He was 
informed that this was out of the question because 
one could not hope to reduce a dislocation in this 
region that had existed more than a year, much less 
hope for an accidental readjustment, and at the 
same time avoid an injury to the medulla. It was 
agreed that an effort at manual reduction should 
be made and, if unsuccessful, an immediate open 
operation should be done. 

Accordingly, under complete ether anaesthesia, 
guarded rotary manipulations with pressure over 
the prominent cervical spine were carried out and, 
as was expected, without results. The patient was 
placed in the ventral position and brought forward 
on the operating table so that his shoulders rested 
on its edge and the forehead was placed on a Gushing 
bench. A laminectomy had been planned because 
it was considered impossible to effect a safe operative 
replacement of the dislocated atlas after having been 
displaced for more than a year. The chief object 
to be achieved was to remove the left axial facet 
as well as the lamina to enable the patient to elevate 
his head so as to relieve the pressure of the chin 
on the chest. Through the usual posterior incision 
the arch of the atlas together with the left superior 
articular surface was removed with a rongeur 
forceps. A distinct anteroposterior movement of 
the head could not yet be made. The right atlo- 
occipital articulation was affected only in a rotary 



GENERAL SURGERY — SURGERY OF THE NERVOUS SYSTEM 



49 



way, and as its articular surfaces were in contact 
and immovable it was decided to remove enough of 
the articulation to mobilize it. This was accom- 
plished so that anteroposterior movements became 
fairly good. The wound was closed and dressed in 
the usual aseptic manner. The operative recovery 
was normal. The immediate operative effect was 



to permit the raising of the head so that the chin 
was free from the chest enabling the patient to mas- 
ticate and speak freely. With effort the head could 
be elevated to a normal position but he was not 
able to maintain it for more than a few minutes. 
There was moderate rotation. Pain and muscular 
rigidity had disappeared. 



SURGERY OF THE NERVOUS SYSTEM 



Gosset, A. : Complete Section of Left Radial Nerve; 
Nerve-Suture; Return of Voluntary Movement 
After 150 Days (Section complete du nerf radial 
gauche; suture nerveuse; retour des mouvements 
voluntaires apres 150 jours). Bull. et'Mem.Soc. de 
chir. de Par., 19 16, xlii, 524. 

Gosset gives the details of a case of left radial 
paralysis operated upon by him in February, 191 5, 
in which total section of the nerve was found and the 
nerve sutured. Five months later there was return 
of voluntary movements. He refers to two similar 
cases previously reported by him. W. A. Brennan. 

Monsaingeon: Inclusion of the Radial Nerve in a 
Cicatrix; Total Radial Paralysis; Liberation of 
the Nerve; Immediate Reappearance of Motion 
and Sensation (Inclusion du nerf radial dans une 
cicatrice paralysis radial totale; liberation du nerf; 
reapparition immediate de la motility et de la sensi- 
bilit6). Bull, et mem. Soc. de chir. de Par., 1916, 
xlii, 408. 

In the great majority of cases the result of 
operative intervention in lesions of the nerves have 
had but a temporary success, and it is only after 
a long interval that we can be sure of a favorable 
result. Lesions of this kind may be divided into 
two classes: those in which there is complete section 
necessitating suture; and those in which the con- 
tinuity of the nerve is merely disturbed and its 
physiological functioning prevented, which only 
requires freeing of the nerve. 

In the first class, i. e., nerve-suturing, favorable 
results are exceptional. In 70 interventions Walther 
had 19 cases of complete or incomplete nerve- 
section in which he was unable to note any favorable 
result after four months. Tufiier and Dumas 
stated that in 19 nerve-sutures done by them there 
was no recovery. The results obtained in freeing 
nerves and re-establishing continuity are very 
different. Wiarts' statistics show 24 per cent 
complete recovery. 

Monsaingeon reports a case of a man wounded 
in the left arm followed by paralysis and almost 
complete loss of sensation. Intervention was made 
68 days later. The radial nerve was found embedded 
in the cicatrix and freed. In less than 8 days there 
was a disappearance of the paralysis and a complete 
restoration of sensation. 

Kirmisson who submits this report of Mon- 
saingeon mentions a similar case which came under 



his own observation, where after a fracture of the 
right humerus there was complete radial paralysis. 
Pressure on the cicatrix which corresponded to the 
point where the radial nerve passed over the ex- 
ternal edge of the humerus was painful. After 
incision the nerve was easily traced and freed. At 
the time of reporting nearly twelve months later 
the patient is entirely well. W. A. Brennan. 

Rogers, M. H.: An Operation for the Correction 
of the Deformity Due to Obstetrical Paralysis. 

Boston M. & S. J., 1916. clxxiv, 163. 

In this deformity the anterior surface of the arm 
and forearm are rotated inward. The operation 
suggested attempts to correct this deformity by 
doing an osteotomy of the upper portion of the 
humerus about two inches below the shoulder-joint, 
followed by a one-quarter rotation of the whole 
arm below the line of fracture. An incison is made 
between the muscle planes sufficiently long to be sure 
that there is no nerve involvement. J. H. Skiles. 

Edinger, L. : The Uniting of Divided Nerves (Ueber 
die vereinigung getrennter Nerven Grundsaetz- 
liches und Mitteilung eines neuen verfahrens). 
Muenchen med. Wchnschr., 1916, Ixiii, 225. 

Edinger has found that there is often great diffi- 
culty in the union of the ends of severed nerves. 
The regenerated nerve-fibers which are thrown out 
by the ganglion cells can easily be diverted from 
their course by any mechanical obstruction, such 
as a blood-clot, and union between the stumps can 
therefore be prevented. He shows that this is the 
case by his own observation and those of others 
whom he quotes. 

The only way that the regenerated fibers may be 
kept in the proper direction to effect union is to 
permit them to grow in a tube. Nevertheless the 
attempts made to grow nerve-fibers in tubes by 
previous workers did not give good results because 
it was necessary for the fibers to be surrounded 
in the tube by a suitable environment for growth. 
The various experiments of Edinger demonstrated 
that human nerve-fibers grow best when the two 
disunited ends are inserted in an artery filled with 
agar jelly. This is the new procedure which he 
advocates. A number of such tubes have been 
prepared and distributed for use to operating neu- 
rologists. 



5° 



INTERNATIONAL ABSTRACT OF SURGERY 



Edinger has seen the results obtained by Ludloff 
and Hasslauer with 14 patients treated in this man- 
ner, in which cases the distance between the dis- 
united nerve-ends varied from 5 to 15 cm. In 
every case there was clear evidence of good progress 
of regeneration in the nerve. Within a few weeks 



the anaesthesia area became much reduced. He 
mentions particularly a case in which 10 cm. of the 
tibial and 8 cm. of the popliteal nerve had been 
resected. After inserting the agar jelly tube the 
return of the plantar reflexes was demonstrable 
after 16 days. W. A. Brennan. 



MISCELLANEOUS 



CLINICAL ENTITIES — TUMORS, ULCERS, 
ABSCESSES, ETC. 

Byford, H. T.: The Etiology and Prophylaxis of 
Cancer. Illinois M. J., 19 16, xxxix, 81. 

The author presents a few fairly well established 
facts that have led him to draw certain conclusions 
with regard to the etiology, and from these conclu- 
sions to formulate such recommendations of a 
prophylactic nature as they may seem to justify. 

We are justified in assuming, for argument's sake, 
that carcinoma is an infection and that it will not 
be a waste of time to make a review of facts and 
probabilities on this basis. 

Although carcinoma is sometimes inoculated into 
the skin or other external epithelial surface, it is in a 
great preponderance of cases introduced into the 
system with the food. 

The human faeces are carriers of germs of car- 
cinoma, both in individuals affected with the dis- 
ease and in many who are not. The same may be 
said as to the faeces of the dog and the cat. 

The occurrence of primary infection in the colon 
and upper rectum shows that the germs that get 
by the pancreatic secretions can survive to infect 
the rectum. If they reach the rectum alive they 
can, of course, be passed out and may find lodgment 
elsewhere. 

Those who are most subject to carcinoma are 
those who work in dirt and eat the greatest variety 
of food. Thus chimney-sweeps, industrial laborers 
in large towns, city laborers, furriers, and carpenters, 
all of whom have a high rate of mortality, work in 
dirt and have not always the means nor incentive 
for frequent washing; while pressmen, compositors, 
and printers, whose working materials are protected 
from outside contamination, and whose surroundings 
are such that they can and do wash and clean up 
when they go to lunch and go home from work, 
have a lower rate. 

There are probably several factors that have some 
influence upon the increase of cancer in recent years. 
The increase of railroad trafiic may be supposed to 
have some effect in spreading infection through 
travel of individuals and through the enormous 
amount of cold storage food that is carried every- 
where. Some of the travelers and some of the food 
must be infected. 

Since duodenal ulcer is a more common lesion 
than gastric ulcer and yet seldom becomes infected 
with carcinoma, and since trypsin, which is poured 



into the duodenum, also prevents continued super- 
ficial development of carcinoma on surfaces with 
which it is kept in contact, the question arises 
whether trypsin, or possibly some vegetable fer- 
ment or synthetic imitation, could not be used for 
the destruction of the disease or the production of 
immunity. 'Whether injections of trypsin or a 
similar substance into and around the carcinomatous 
mass, or into the afferent blood-vessels or into the 
colon or the general circulation could be worked 
out so as to be curative, is perhaps worthy of 
serious thought, if not experiment. 

The following recommendations are suggested: 

1. Carcinoma should be considered an infectious 
disease. 

2. Precautions against the spread of the infection 
should be taken by the community, as well as by the 
individuals affected. 

3. Foods, particularly fruits and vegetables, 
should be protected from contamination at their 
source and in transit. 

4. The disposal of human excrement in suburban 
and populous rural and manufacturing districts 
should be such as to avoid possible contamination of 
the surface soil. The faeces of patients with car- 
cinoma of the alimentary canal and pelvic organs 
should receive the same attention as those of pa- 
tients from typhoid fever or cholera. Women 
should be taught the infectious nature of normal 
stools, with particular reference to keeping the 
perineum free from contamination. 

5. The number of cats and dogs in populous 
districts should be restricted and they should not be 
allowed to roam about the streets by day or night. 
The excess should be killed. Means should be 
taken for the extermination of rats, mice, cock- 
roaches, and other vermin. 

6. Individuals whose occupations are known to 
expose them to great risk of infection from carcino- 
ma should be taught that it may get into their 
systems either through the irritated skin or by way 
of the alimentary canal. 

7i All epithelial areas affected with chronic irrita- 
tion and erosion should be attended to. An attempt 
might also be made to prevent infection of ulcerated 
and eroded surfaces in the alimentary canal. Pa- 
tients with such lesions should avoid all unsterilized 
food that might be contaminated. 

8. Municipal authorities should put carcinoma 
upon the list of diseases to be reported in order that 
the patients may be traced and taught how to take 



GENERAL SURGERY — MISCELLANEOUS 



51 



care of themselves and their infected discharges, and 
that none of those living with them be allowed to 
handle foodstuflfs for the market, 

9. The blood of patients with carcinoma should 
be exhaustively studied with reference to the dis- 
covery of something that will increase immunity. 

10. The time would seem to be ripe for teaching 
the public something concerning the erroneous 
notions about diet that are prevalent among the 
idle rich and prosperous poor in order that they 
may stop manufacturing the serious forms of gastro- 
intestinal disease that have of late years shown such 
an alarming increase in frequency, the seeds of 
which are shown in adolescence and the fruits of 
which are harvested at maturity and in senescence. 

11. Women who have not borne children for 
several years should be warned of the danger of 
developing carcinoma and should not only be on the 
lookout for symptoms, but should submit to a 
pelvic examination at least twice a year until it is 
evident that the mucous membranes are healthy 
and are remaining so. Edward L. Cornell. 

Moullin, C. M.: The Classification of Tumors. 

Ann. Surg., Phila., 1916, Ixiii, 257. 

The great variety of tumors makes their classifica- 
tion difficult and, according to the author, no 
previous classification can be said to meet all the 
requirements. Instead of classifying tumors on 
the basis of malignancy, structure, or origin, the 
author submits what he believes to be a better 
classification. 

Using the word in its ordinary acceptation, tumors 
are divided into two classes. One is due to the 
reproductive power that all tissues naturally possess 
when suddenly aroused into action; the other, 
to changes that should take place in development 
not being efficiently carried out. The power of 
reproducing their like directly, without assistance 
from any other source, is the common property of all 
living things and all parts. The extent to which 
they make use of this power furnishes the most 
satisfactory basis for the classification of tissues 
and of the tumors that grow from them. At a 
very early period of development one group of 
cells is marked off for reproduction, the germ cells. 
The rest of the cells, known as the somatic cells, 
become specialized for other kinds of work and grad- 
ually lose their reproductive power. Each cell as 
it develops passes through all the stages through 
which its ancestors passed in the course of evolution. 
The structure of a tumor depends upon the parent 
stem, and always resembles it though it is never so 
perfect. Malignancy of the tumor depends, then, 
upon the maturity of the parent cell at the moment 
the bud began to grow. If the parent cell has al- 
ready reached the adult age, the bud will increase 
proportionately slow, pushing the surrounding struc- 
tures to one side instead of invading them. There 
is no separate class of malignant tumors, rapidly 
growing malignant forms occurring in all classes. 

Under the head of tumors of the germ organ and 



its derivatives, the author has included foetus, in- 
ternal teratomata, ovarian dermoids, and ovarian 
adenomata. The classification of tumors that grow 
from the somatic cells depends upon that adopted 
for the tissues themselves. Every organ and every 
tissue has its own kind of tumor. Tumors of the 
thyroid may resemble those of the prostate, but 
behave very differently. 

Tumors due to errors in development differ from 
those caused by the sudden awakening of the re- 
productive power of the tissues in that they do not 
possess an independent existence and do not belong 
to the same generation as the structures from which 
they grow or to the next. Premature arrest of 
development is one of the most important causes of 
tumor formation. This not only involves the pro- 
gressive advance of tissues, but the disappearance 
of those which have ceased to be of use. This group 
includes such tumors as the meningomyelocele, 
caused by failure of the medullary groove to close 
at its proper time, and also those tumors develop- 
ing from the remains of the hyolingual duct, or the 
wolffian ducts, or wherever tissues have failed to 
disappear in the evolution of the organism. 

Gatewood. 

Allan, A. P.: Phantom Tumors. Clin. J., 1916, xlv, 
54- 

The typical phantom tumor is resonant and 
smooth, conforming to that muscle or group of 
muscles with which it is associated; it is always 
resonant, but less so than the neighboring parietes. 
It is said to disappear during sleep, but it does not 
invariably do so. Pain is absent, though some 
cases run into a cramp, in which case the pain is 
intense. 

The author reports two cases, both in women. 
In one the tumor was due to a contraction of the 
right rectus muscle. This patient recovered under 
suggestion. The second was due to a dilated 
caecum following mucous colitis. It disappeared. 

The treatment is to remove any factor of irrita- 
tion that may be present or, if due to occupation, 
consider the condition for a remedy. Galvanism 
and massage have proved useful and purely neu- 
rotic cases respond excellently to "suggestion." 
It is well to bear in mind "protective phantom 
tumors" and to seek for the cause in deeper or other 
organs. Edward L. Cornell. 

Roberts, J. B.: A Further Note on the Etiology 
of Surgical Scarlatina. Tr. Am. Surg. Ass., Wash- 
ington, 19 16, May. 

The author states his belief that true scarlatina 
sometimes occurs by the introduction of the infect- 
ing agent through a breach in the skin instead of 
by the usual faucial or nasal route; and in his opinion 
there is reason to believe that the difficulty in isolat- 
ing the infecting organism is probably due to its 
ultramicroscopic size and its filterable nature. He 
also suggests that the anginose affection, termed 
scarlatina, may cover more than one specific infec- 



52 



INTERNATIONAL ABSTRACT OF SURGERY 



tion. This last opinion is based upon the con- 
fusion which has long existed between similar 
infections such as typhus and typhoid fever, 
malarial and yellow fever, and other well-known 
infections with similar symptoms. Reference is 
made to the papers of McCarty and Hamilton. He 
believes that many cases of so-called post-operative 
scarlet fever are probably of septic origin or are due 
to vasomotor influences. Instances doubtless occur 
where the true scarlatinal affection is simply a 
coincidence in a patient already suffering from a 
wound received about the time of exposure to the 
infection. 

The cases are cited of Strickler, who about 20 
years ago inoculated children with saliva of scarlet 
fever patients in the hope of producing immunity. 
Strickler believed that he actually caused acute 
scarlet fever by introducing the infection through a 
wound in the skin. The latest investigation of the 
etiology of this disease known to the author is that 
of Mallory and Medlar of Boston who found a 
gram-positive bacillus which they thought to be the 
true causative agent. 

SERA, VACCINES, AND FERMENTS 

Gellhaus: Some Observations Regarding Collar- 
gol Injections in Small Doses (Einige Beobach- 
tungen bei Kollargolinjektionen in kleinin Dosen). 
Muenchen med. Wchnschr., 1916, Ixiii, 191. 

The author draws attention to the efficacy of 
small intravenous injections of collargol in infective 
diseases. In his earlier cases he used a 2 and 3 per 
cent solution, but in his recent practice he has 
reduced the strength to i per cent and in the case of 
children to 0.5 per cent. 

He has treated altogether 143 cases of different 
inflammatory types with collargol. These include 
appendicitis, peritonitis, gonorrhoea, pneumonia, 
etc. As a general rule good results are obtained 
when collargol is injected in the early stages of the 
inflammatory process. The action of collargol is 
found to be powerless only when the infection is of 
a high degree of virulence. 

Of the cases treated, 34 were cases of appendicitis. 
Of these, operation was necessary in 6. Of the 
others, i died and 27 recovered with 2 cases of relapse. 
The early use of collargol not only facilitates the 
results of operation when such is necessary for in- 
flammatory conditions, but it may obviate opera- 
tion altogether. W. A. Brennan. 

BLOOD 

Rous, P., and Turner, J. R.: The Preservation of 
Living Red Blood-Cells in Vitro; Methods of 
Preservation, J.Exp. Med., 1916, xxiii, 219. 

The authors state that there is practically no 
mention in the literature of attempts to keep red 
blood-cells alive for a long time in vitro, notwith- 
standing the great practical advantage that such a 
method would afford. They believe that red blood- 
cells could be used for serum reactions, or for cul- 



ture media, or even under certain circumstances for 
transfusion. 

For their experiments they made use of the cells 
of the rabbit, dog, sheep, and man. They seem to 
have proven conclusively that if washed red cells 
are to be properly preserved they must be protected 
during washing, and that plasma cannot be used for 
this purpose. They found that gelatin in one- 
eighth to one-fourth per cent in Locke's solution 
protected cells absolutely against injury during 
washing and even during prolonged shaking. This 
injury may express itself in haemolysis only after 
the cells have been kept for some days. They found 
it greatest in the case of dog corpuscles, and well 
marked in sheep and rabbit cells. The fragility 
of the red cells, as indicated by washing or shaking 
them in salt solution, they state, is different, not 
only for different species but for different individuals. 
It varies independently of the resistance to hypo- 
tonic solutions. The authors point out that the pro- 
tection of fragile erythrocytes during washing is 
essential if they are to be preserved in vitro for any 
considerable time. The addition of a little gelatin 
— one-eighth per cent — to the wash fluid was found 
to suffice for this purpose, and by its use the period 
of survival in salt solutions of washed rabbit, sheep, 
and dog cells was greatly prolonged. 

Though gelatin acted as a protection for red cells 
they did not find it preservative of them in the real 
sense. Cells did not last longer when gelatin was 
added to the fluids in which they were kept. Locke's 
solution, though probably better than Ringer's 
solution, or a sodium chloride solution, as a medium 
in which to keep red cells, was ultimately harmful. 
The addition of innocuous colloids did not improve 
it. But the sugars, especially dextrose and sac- 
charose, had, the authors state, a remarkable power 
to prevent its injurious action, and possessed, in 
addition, preservative qualities. Cells washed in 
gelatin-Locke's solution and placed in a mixture of 
Locke's solution with an isotonic, watery solution 
of a sugar remained intact for a long time — nearly 
two months in the case of sheep cells. The kept 
cells went easily into suspension free of clumps, 
they passed readily through paper filters, took up 
and gave off oxygen, and when used for the Wasser- 
mann reaction behaved exactly as did fresh cells 
from the same individual. The best preservative 
solutions, the authors state, are approximately isp- 
tonic with the blood serum. If the cells are to be 
much handled gelatin should be present, for the 
sugars it was found did not protect against mechan- 
ical injury. George E. Beilby. 

Morriss, W, H,: Secondary Haemorrhage in Mili- 
tary Surgery. Mil. Surgeon, 1916, xxxviii, 131. 

The inefficiency of accepted methods of controll- 
ing wound infections has been one of the surgical 
surprises of the present war. Almost every case is 
infected, many of them seriously. Serious complica- 
tions frequently arise and one of the most serious is 
secondary haemorrhage. 



GENERAL SURGERY — MISCELLANEOUS 



S3 



Secondary haemorrhage may originate from one 
of several causes: (i) A thrombus closing the end 
of a severed vessel may become infected, digested, 
and haemorrhage result. (2) A vessel wall may be 
contused and haemorrhage occur only after slough- 
ing has occurred. (3) An intact vessel wall may be 
eroded by direct extension of a sloughing infection 
from neighboring tissues. (4) A spurious aneurism 
may have its sac wall infected and rupture occur. 

Other factors besides infection which may lead to 
secondary haemorrhage are: (i) a hasmorrhagic 
diathesis may exist; (2) the jolting and jarring 
incident to transportation may excite haemorrhage; 
and (3) a foreign body in the wound may cause 
haemorrhage by eroding the vessel wall. 

The onset of secondary haemorrhage is usually 
sudden and the patient may be found in collapse, 
lying in a pool of blood. 

The treatment should attempt the control of the 
haemorrhage and the resuscitation of the patient. 
The control of the haemorrhage may be secured by 
ligation of the bleeding vessel as far above the area 
of infection as possible. Frequently, however, 
recurrent haemorrhages occur and usually amputa- 
tion, if the bleeding vessel be in a limb, as high as 
necessary, is undertaken. The resuscitation of the 
patient is effected chiefly by normal saline hypo- 
dermoclysis and blood-transfusion. 
The author reports five cases coming under his 
own observation and gives a complete history of 
each case. J. H. Skiles. 

Hess, A. F.: The Blood and the Blood-Vessels in 
Hsemophilia and Other Haemorrhagic Diseases. 

Arch. Int. Med., 1916, xvii, 203. 

Hess believes that the group termed "the haem- 
orrhagic diseases" includes a large number of ab- 
normal conditions, and that, at the present time, 
it is a fruitless task to attempt to unravel the various 
entities embraced by the clinical conditions which 
are assembled under this general head. This he 
considers as due partly to the fact that the phys- 
iology of the coagulation of the blood is still incom- 
pletely understood, partly because of the impos- 
sibility of analyzing the various factors concerned in 
coagulation, and in part because these haemorrhagic 
states have been incompletely observed from a 
clinical point of view. 

In this investigation, therefore, the author con- 
siders the condition of purpura rather as an entity 
and compares it to haemophilia. The main points 
in his study may be summarized as follows: 

The coagulation time of the plasma in haemophilia 
at times may become normal without the occurrence 
of haemorrhage or other apparent change in the 
condition of the patient. 

The estimation of the number of blood-platelets 
is of great value, as has been found by others, in 
differentiating between purpura and haemophilia. 
In some cases of purpura, the platelets are abnormal 
and may be differentiated, like other macrocytes 



and microcytes of the blood, into macroplatelets and 
microplatelets. 

The puncture test — the reaction following sub- 
cutaneous puncture of the skin — is an aid to diagno- 
sis. In haemophilia a haemorrhagic area rarely 
results from this procedure; in purpura it is the rule. 

The capillary resistance test is also of value. By 
this is understood the reaction following the applica- 
tion for a definite period of a tourniquet to the upper 
arm. In purpura, this results in petechial haemor- 
rhages on the forearm; in haemophilia the effect is 
negative. 

There is an hereditary purpura as well as an 
hereditary haemophilia. This type of purpura should 
be more generally recognized, so that these cases 
will not, on account of their hereditary history, con- 
tinue to be regarded as haemophilia. 

The male member of a family may be a "bleeder" 
of the haemophiliac tjq^e and the female of the pur- 
puric type. Two families are described in which one 
member suffered from haemophilia and another from 
purpura. 

Haemophilia may be atypical: A case is reported 
which showed a calcium deficiency, as borne out 
by various chemical and clinical tests (haemophilia 
calcipriva) . 

In some cases manifesting haemorrhage, the vessels 
seem to be involved. This weakness is encountered 
in children and may be congenital; it may appear in 
the course of an infectious disease, or of a nutritional 
disorder, such as infantile scurvy. 

In the classical case the differentiation between 
haemophilia and purpura is simple. The picture 
of a typical haemophiliac is a male, with a hereditary 
history of bleeding, whose blood manifests a defi- 
nite delay in coagulation time, whose platelets are 
normal in number, "bleeding-time" not increased, 
who shows no haemorrhagic reaction following sub- 
cutaneous puncture of the skin, and a negative 
capillary resistance test. A typical case of purpura 
is found to be quite different : the patient may be a 
male or a female; the plasma coagulates in almost 
normal time and the number of blood-platelets is 
decreased (frequently below 100,000 in number); 
there is definite subcutaneous haemorrhage, follow- 
ing puncture of the skin; an increase of the bleeding 
time; and the development of a large number of 
petechial haemorrhages following the application of 
a tourniquet. George E. Beilby. 

Meyer, W.: The Conservative Treatment of Gan- 
grene of the Extremities Due to Thrombo- 
angiitis Obliterans. Ann. Surg., Phila., 1916, 
Ixiii, 280. 

After a discussion of a number of cases which 
the author has treated conservatively with most 
encouraging results, and a review of the various 
methods of treatment of both acute and chronic 
gangrene of the extremities, the author discusses 
in detail that type due to thrombo-angiitis oblit- 
erans. He believes that conservative treatment 
should always be instituted before an amputation 



54 



INTERNATIONAL ABSTRACT OF SURGERY 



is considered. If gangrene has begun, it is obviously 
impossible to replace what is dead. The progress 
may, however, be stayed; old obstinate ulcers 
may heal, and otherwise uncontrollable pain can 
be relieved. 

Conservative treatment consists in the use of 
superheated air, or Bier's hyperaemia. This is best 
combined with systematic hypodermoclysis of 
Ringer's solution. If these simpler methods prove 
of no avail, conservative operative measures are 
indicated; viz., tying of the femoral vein or arterio- 
venous anastomosis. Both of the latter methods 
should be subjected to further careful clinical 
research as to their real value. Superheated air 
treatment may bring improvement of the symptoms, 
but a lasting beneficial effect is rarely seen. It 
seldom controls the pain. The systematic hypo- 
dermic injection of 400 to 500 ccm. of Ringer's 
solution (Matesima-Koga) daily, or every second or 
third day, deserves a definite place in the con- 
servative treatment. Its effects may be lasting or 
temporary, but if temporary, repetition usually 
again brings improvement. Two such series of 
injections represent a sufficient test as to their 
usefulness. Internally, a simultaneous adminis- 
tration of organotherapeutic preparations deserves 
a careful test. Since women seem to be immune to 
the disease, it has been suggested that something 
in their system protects them, and for this, if for no 
other reason, extracts of organs should be given a 
trial. 

Inflammation of the wall of the blood-vessels of 
the next higher group to the capillaries, arterial as 
well as venous, seems to be responsible for the 
thrombosis (Buerger). Its cause may be microbic, 
but the fact that women are immune again seems 
to argue against this. The increased viscosity 
of the blood, viz., blood that is thicker than normal, 
seems to play an important role in the etiology of 
the disease. It is possible that an altered quality 
of the blood as such represents a cause for the 
occurrence of the thrombosis and the subsequent 
gangrene. On the basis of this reasoning, pro- 
cedures which tend to reduce the coagulability of 
the blood within the body deserve to be tried in an 
effort to find the underlying cause of the trouble. 
Intravenous injections of anticoagulating sub- 
stances, such as a 2 per cent watery solution of 
sodium citrate, may prove to be a useful adjuvant 
to the systemic hypodermic administration of 
Ringer's solution. Gatewood. 

McLean, A.: Venous Thrombosis and Embolism, 
Its Cause, Significance, and Consequences. 

Penn. M. J., 1916, xlx, 318. 

The author describes some experiments on dogs 
undertaken to explain the cause of the thrombotic 
process which occurs, for instance, as a femoral 
thrombosis following an apparently clean append- 
ectomy, where the common etiological factors, 
such as: (i) trauma to the intima, (2) stagnation or 



slowing of the blood stream, (3) chemical changes 
in the blood, and (4) infection, are wanting. 

He was impressed with the tremendous amount 
of injury a vein could withstand without the forma- 
tion of a thrombus at the site of the injury. 

The following phenomena were noticed in the 
course of the experiments: 

1. When a vein is ligated in continuity, the blood 
in the vein will clot only on one side of the point of 
ligation, that is, the side from which the blood is 
coming. 

2. In ligating a vein between two ligatures (two 
inches apart) the blood between the ligatures clots 
very slowly, and if left for a week or more the con- 
tents of the ligated vein will have completely disap- 
peared, a fibrous cordlike structure alone remaining. 

3. The same result is accomplished by ligating 
an artery between two ligatures. 

4. Simple crushing of a vein will not cause a clot 
at the point of crushing. The crushing can be re- 
peated in forty-eight hours and a clot will not form at 
the site; examination of the repeatedly crushed vein 
two weeks after the last crushing, will show a thick- 
ening of all the coats of the vein, the intima re- 
maining smooth and glistening. 

5. Crushing the vein with the subsequent intro- 
duction of a 24-hour bouillon culture of staphylo- 
cocci, and again crushing the vein, grinding the 
staphylococci into the vein wall, did not produce a 
clot or thrombus at the site of the crushing or the 
injection of the bacteria. 

6. The introduction of a sterile thread into the 
lumen of a vein, allowing one-half to three-fourths 
of an inch to be suspended inside the vein, failed to 
produce a clot or thrombus. 

7. The same experiment was negative in the 
artery, allowing the thread to remain four, five and 
seven days. 

8. Thread infected with staphylococcus albus or 
aureus will cause a thrombus in three or four days. 

9. Thread infected with colon bacillus or staphy- 
lococcus aureus introduced into an artery caused the 
formation of a firm clot. 

10. Sterile thread one-half and one inch long 
"let go" in the circulation caused no symptoms. 

11. Infected thread (colon bacillus) "let go" 
caused death in three and one-half days. Thread 
infected with blood-clot recovered in the right lung. 

In reviewing his records of the past two years in 
1,610 laparotomies, thrombosis and embolism fol- 
lowed in T)^ cases, 2.2 per cent. There were 9 fatal 
cases of embolism. There were 3 cases of pulmonary 
embolism followed by abscess and recovery; 2 of 
hepatic embolism, followed by abscess with one 
recovery; 2 of cerebral embolism followed by death. 
There were fifteen cases of femoral thrombosis follow- 
ing pelvic operations. 

It is worthy of note that in all the cases of em- 
bolism and thrombosis in the entire series, there was 
only one case of embolism with recovery, and no 
cases at all of thrombosis, that followed operations 
in the upper abdomen. Lucian H. Landry. 



GENERAL SURGERY — MISCELLANEOUS 



55 



Painter, C. F.: The Operative Treatment of 
Thrombo-Angiitis Obliterans. St. Paul M. J., 
1916, xviii, 41. 

The author cites a number of cases that have 
come under his observation, which he puts in the 
classification so well described by Leo Buerger. 

All of his cases were in young Russian Jews. Occu- 
pation can not be traced as a causative factor as his 
cases are found in many different callings. How- 
ever, his observations coincide with Erb's, in so 
much as excessive cigarette smoking and inveterate 
tea drinking has been noticed in all his cases. The 
unstable nervous system of the Jewish race as a 
whole may play a part in this condition, as almost 
all of his patients have been temperamentally 
neurotics. 

The patients complain of disagreeable sensations 
in the feet and sometimes in the calves of the legs; 
this increases to pain and is associated with a con- 
gestion of the toes, which extends to the dorsum 
of the foot, possibly as high as the malleoli. 

A dependent position of the foot aggravates this 
congestion and the pain is more severe and of a 
burning character the longer the foot is allowed to 
hang. Pain and congestion are appreciably lessened 
by elevation. Anterior and posterior tibial pvilse is 
very feeble or absent. Gangrenous areas may be 
noted, if the caliber of the vessel is sufficiently 
encroached upon. 

Pseudo-arthritides are quite prevalent among the 
Jewish people, as described by Solis-Cohen. A 
certain amount of apparently bona fide capsular 
thickening gradually develops, even in these purely 
functional or neurotic joint disturbances. If such 
actual physical changes can take place in and about 
joints as the result of a non-inflammatory condition, 
the author advances the hypothesis that given the 
activity of a similarly disturbed nervous mechanism 
in the peripheral vessels of the extremities, one 
might expect to find these vessels occupied by a 
thrombus which would attach itself to the walls and 
organize into connective tissue, thus narrowing or 
occluding the lumen of the vessels. 

The author is in favor of conservative treatment 
rather than amputation, especially in the early 
cases. This treatment consists in rest; elevation of 
the limb, combined with keeping it well wrapped 
in cotton wool; discontinuing the use of tobacco, 
alcohol, tea, etc. 

This necessarily means a long tedious treatment, 
but with sufficient means or hospital facilities, the 
end-results justify the sacrifice of time. 

LUCIAN H. L.\NDRY. 

Lindeman, E.: Reactions Following Blood-Trans- 
fusion by the Syringe Cannula System. /. 

Am. M. Ass., 19 16, Ixvi, 624. 

Lindeman states that the syringe cannula system 
has greatly simplified the procedure of blood trans- 
fusion, which now occupies a prominent and per- 
manent place in therapeutics. In the first 150 



transfusions by his method, chill, followed by fever, 
occurred in approximately i:^ per cent. He has 
found that haemolysis never occurrs without chills 
and fever, unless the patient dies during, or shortly 
after, the transfusion. He infers therefore that 
chills and fever in transfusion are due to haemoglobin 
set free in the circulating blood. If the haemoglobin 
set free is abundant, it appears in the urine; when 
the amount is moderate haematoporphyrin appears 
in the urine; when haemolysis is slight no blood 
pigment appears in the urine. 

In this series of 150 cases, the preliminary blood- 
tests for haemolysis and agglutination were con- 
ducted by different serologists. In every case in 
which haemolysis occurred and in which preliminary 
tests had been made, Lindeman had the test re- 
peated later, and in each instance incompatibility 
was detected in the second examination. He infers 
that there was error in the primary examination 
and has set himself the task of eliminating this 
error by personal supervision of the laboratory work 
and of developing refined methods of selection so as 
to prevent even a slight degree of haemolysis, of 
which the only manifestation is chills and fever. 

His technique for testing for haemolysis and 
agglutination are as follows: The red blood-cells of 
the patient and donor are washed three times with 
normal saline; variable quantities of patient's serum 
are placed in three separate small test-tubes; to 
each of these are added 0.25 ccm. of a 2 per cent 
suspension of washed blood-cells of the donor. 
The same is done with the donor's serum and the 
patient's cells. Controls are made of donor's serum 
and donor's cells — patient's serum and patient's 
cells. Controls are also made with donor's cells in 
normal salt solution and patient's cells in normal 
salt solution. The total volume in each tube is 
raised with normal saline to o . 5 ccm. of volume. 
The test-tubes are incubated in a water bath for a 
period of two hours, and readings are made. They 
are then set in the ice-box over night and readings 
are again made the following morning. When a 
case is urgent, the ice-box test is eliminated. 

In the last 155 transfusions performed by the 
syringe cannula system with personally supervised 
preliminary tests no case of haemolysis, and no death 
referable to transfusion, occurred. Chills followed 
by a rise in temperature occurred in sixteen in- 
stances. Adults received from 1,000 to 1,800 ccm. 
in each transfusion, and the quantity enumerated 
was always taken from one donor. No foreign 
substance or anticoagulant was employed in any 
case. 

In the syringe cannula method of Lindeman, the 
entire mass of blood is outside the body for a period 
of from six to ten seconds, regardless of the amount 
transferred. It passes through a minimum amount 
of foreign material. Embolism or clotting never 
occurs in transit. Syringes are cleaned as fast as 
used. Clotting in the syringe can not occur, and 
the blood is transferred uninjured exactly as it 
exists in nature. There are no stopcocks, valves, or 



56 



INTERNATIONAL ABSTRACT OF SURGERY 



rubber tubings about which blood may clot, and 
there is no blind system into which air may leak. 
His conclusions are as follows: 

1. The preliminary haemolytic and agglutination 
tests when properly performed are reliable. 

2. Incidents of haemolysis in transfusion can be 
eliminated entirely. 

3. The reactions which follow transfusion when 
accurate tests are made are eliminated in all except 
9 per cent of the cases. In this 9 per cent, chills 
and fever alone occur. When the quantity is 800 
ccm. or less, chills and fever do not occur. 

4. By careful, accurate, and complete haemolysis 
and agglutinin tests, when work is done skilfully, 
blood-transfusion is robbed of all danger attending 
its use. Albert Ehrenfried. 

Cherry, T. H., and Langrock, E. G.: The Relation 
of HaBmolysis in the Transfusion of Babies 
with the Mothers as Donors. /. Am. M. Ass., 
1916, lxvi/626. 

Cherry and Langrock consider that haemorrhagic 
disease of the newborn is one of the most frequent 
and alarming of the diseases in combating which 
transfusion is required. The subcutaneous injec- 
tion of animal or human serum (Welch) or of whole 
blood (Schloss) has been used with a considerable 
degree of success, but there have also been a great 
many failures. The transfusion of blood, however, 
has given highly gratifying results. 

On account of the close relationship of the matern- 
al and foetal bloods in utero, it is a natural supposi- 
tion that complete compatibility of infant's and 
mother's blood should exist. In order to establish 
this fact, the authors have performed a series of 
haemolytic tests in 34 instances upon newborn 
babies and their own mothers. If it is known before- 
hand that the mother's blood is compatible, it will 
save delay. in finding a compatible donor, in making 
the necessary serological tests, and in the expense 
which these conditions entail. 

In the 34 tests carried out, no haemolysis or agglu- 
tination occurred. Accordingly the authors con- 
clude that all mothers can be used as donors for 
their infants in the transfusion of blood, provided 
no contra-indications exist on the mother's part. 

The authors report one transfusion performed 
since these experiments were concluded, in which, 
without preliminary blood tests, 60 ccm. was success- 
fully transferred from the mother, through the 
external jugular vein, by the indirect syringe pro- 
cedure of Unger. They estimate that 60 to 75 ccm. 
are sufficient to supply the infant with necessary 
elements to promote clotting, and to replace those 
lost by haemorrhage. They recommend the indirect 
method for its simplicity. Albert Ehrenfried. 

Rous, P., and Turner, J. R.: The Preservation of 
Living Red Blood-Cells in Vitro; Transfusion 
of Kept Cells. /. Exp. Med., 1916, xxiii, 239. 

Having described in a previous paper the meth- 
ods whereby red blood-cells may be kept intact for 



long periods in vitro, Rous and Turner have under- 
taken to determine whether cells kept according 
to these methods were alive in the sense that they 
were capable of functioning in the animal body. 
This they have attempted to determine by trans- 
fusion of the kept cells in bulk with appropriate 
control. They have performed many such experi- 
ments, using rabbits. 

In order to determine the availability for func- 
tional uses of red cells kept in vitro by their methods, 
transfusion experiments were carried out with rab- 
bits by which a large part of their blood was replaced 
with kept rabbit cells suspended in Locke's solu- 
tion. It was found that erythrocytes preserved 
in mixtures of blood, sodium citrate, saccharose, 
and water for 14 days, and used to replace normal 
blood, remained in circulation and functioned so 
well that the animal showed no disturbance, and 
the blood count, haemoglobin, and percentage of 
reticulated red cells remained unvaried. Cells 
kept for longer periods, though intact and apparently 
unchanged when transfused, soon left the circula- 
tion. Animals in which this disappearance of 
cells took place on a large scale, remained healthy 
save for the progressing anaemia. The experiments 
proved that, in the exsanguinated rabbit at least, 
transfusion of cells kept for a long time in vitro 
could be used to replace the blood lost, and that 
when the cells had been kept too long but were still 
intact they were disposed of without harm. The 
indications are, the authors state, that kept human 
cells could be profitably employed in the same way. 

Geoe:ge E. Beilby. 

BLOOD AND LYMPH VESSELS 

Eccles, W. M.: A Clinical Lecture on Aneurisms of 
War Wounds. Am. J. Surg., 1916, xxx, 33. 

Eccles classifies 50 cases of traumatic aneurism 
and emphasizes some points in regard to their 
treatment. Of the 50 cases, 30 were arterial and 20 
were arteriovenous; 7 were of the vessels of the 
head and neck, 14 of the vessels of the upper extrem- 
ity, and 29 of the vessels of the lower extremity. 
The popliteal suffered more frequently than any 
other vessel. There were 4 deaths in the series. 

The signs of traumatic aneurisms vary somewhat 
from those of pathological aneurisms. The bruit is 
usually much more marked and the thrill is harsher. 
Where the clot is large the pulsation, bruit, and 
thrill may entirely disappear. 

With regard to the treatment of traumatic aneu- 
risms in general the author makes the following 
suggestions: (i) Delay operation as long as possible 
in order to allow time for a collateral circulation to 
be established. (2) Always be prepared for profuse 
haemorrhage. (3) Make a long incision in order to 
secure an abundance of room. 

The methods of dealing with traumatic aneu- 
risms are three: ligation of vessels, operations on the 
sac, and amputation. 

The application of ligatures to the artery on the 



GENERAL SURGERY — MISCELLANEOUS 



57 



proximal and distal sides of the aneurism is quite 
the best method of treatment. A ligature on the 
proximal side alone is uncertain in its results and 
may not control the bleeding. The ideal method of 
treatment is to apply a tourniquet, open the sac, 
pass a probe into each communicating vessel and 
ligate each one externally, but it is not altogether 
easy and causes a good deal of disturbance. 

Amputation is required if gangrene has set in and 
may possibly be the safest as a primary treatment 
where there is a diffused traumatic arterial aneurism. 

Quadruple ligation with excision of the inter- 
vening portion is the best method of treatment in 
arteriovenous aneurisms. J. W. Turner. 

Haberland, H. F, O.: The Epicrises in Wound 
Aneurisms (Zur Epikrise der Schussaneurysmen). 
Deutsche med. Wchnschr., 1916, xlii, 160. 

In the case of traumatic aneurisms of the extremi- 
ties it is only permissible to speak of a cure when 
complete functional use of the organ has been 
restored and provided there is no serious secondary 
injury. 

Great caution must be observed in making the 
prognosis, owing to the danger of late gangrene 
developing; observation after operation should be 
continued for at least six weeks. 

Early vessel-suture is favorable to early recovery. 
Oval suturing is to be preferred. Arteriovenous 
aneurisms ought always be operated upon on ac- 
count of the danger of embolism. Conservative 
treatment will not effect an anatomic cure. 

W. A. Brennan. 

Judd, E. S. : Cirsoid Aneurism. St. Paul M. J., 1916, 
xviii, 48. 

The author reports quite an extensive case in- 
volving the entire forehead, in which there was a 
large mass over the bridge of the nose, which ex- 
tended into the right lids, entirely closing the eye. 
The dilated vessels passed back through the scalp 
to the occipital region. The right facial artery was 
considerably dilated as it crossed the border of the 
jaw at the anterior border of the massiter muscle. 

Under ether and local anaesthesia, the right ex- 
ternal carotid was ligated, as well as the facial, just 
above the submaxillary gland. The pulastion was 
considerably diminished in the prominent part of 
the angioma, but in a few days the condition was the 
same as before operation. 

Six days later, the opposite external carotid was 
ligated, which practically stilled the vessels. The 
patient was comfortable for a few days, when the 
skin of the scalp over the aneurism became tense, 
red, and extremely painful. The scalp and tissue 
about the face were very sensitive. The pain was 
so great that morphine had to be administered 
freely. 

Five days later, the scalp was incised from the 
glabella to the inion, down to the periosteum. The 
scalp was reflected on both sides and the dilated and 
thrombosed vessels were dissected out. There was 



no tendency to haemorrhage or active bleeding. 
The scalp was sutured. One or two separate in- 
cisions about the face and temporal region were 
necessary and the vessels in these regions extirpated. 
Sloughing occurred in one of the scalp-flaps. The 
convalescence was satisfactory and the patient has 
been doing well since the operation (March 2, 1912). 

The author discusses the various forms of treat- 
ment which have been advocated by several ob- 
servers, such as the ligation of the afferent vessels; 
the coagulation of blood by means of various injec- 
tions; galvanocautery; electropuncture, etc. When 
the condition appears in the extremities, amputation 
may have to be resorted to. Some observers recom- 
mend leaving these tumors alone, unless the exten- 
sion or severity of the condition endangers the life 
of the patient. Compression of the tumor is a simple 
but ineffectual mode of treatment. Ligation of the 
temporal and occipital, also the branches of the 
artery leading to the affected part, has been tried 
with no success. 

While ligation of one external carotid may reduce 
the supply to the scalp, the ligation of both external 
carotids is more efficacious. Ligation of the common 
carotid is far more dangerous, especially in the aged, 
and is not as efficacious as the ligation of the external 
carotid, as the branches involved spring from the 
latter vessel. 

Fifty-one single ligations and forty-eight double 
ligations of the external carotid have been performed 
in the Rochester clinic without a single death; while 
in eight cases in which one common carotid was 
ligated, there were two deaths. 

LuciAN H. Landry. 

Kuettner, H. : Experience in Injuries of the Large 
Blood-Vessels in War (Meine Erfahrungen in der 
Kriegschirurgie der grossen Blutgefaessstaemme). 
Berl. klin. Wchnschr., 1916, liii, loi. 

Kuettner's experience with injuries of the larger 
vessels, including aneurisms, is based upon 249 
cases in the Graeco-Turkish, South African, and the 
present wars. 

Next to nerve injuries aneurisms are the most 
interesting to the surgeon. These classes of injuries 
give the greatest contrasts in peace and war. In 
vascular surgery, however, unlike surgery of the 
nerves, the surgeon can see the success or failure 
of his intervention at once without having to 
wait an indefinite period. 

Injuries to the large blood-vessels are so serious 
and the operatory diflaculties so great that their 
treatment should be left to the most experienced 
and skillful surgeons. Kuettner classifies blood- 
vessel injuries in three groups: (i) injuries with 
external haemorrhage, (2) injuries with internal 
haemorrhage, and (3) complete aneurisms. 

Regarding external haemorrhages Kuettner states 
that the percentage of soldiers who die from haemor- 
rhage on the battlefield depends on the kind of 
battle and the class of weapon. In artillery wounds, 
fragments of shells and expeciaUy pieces of steel 



58 



INTERNATIONAL ABSTRACT OF SURGERY 



grenades cut through the vessel like a knife and 
there is a large external haemorrhage. The crushing 
effect even of the large modern projectiles counts 
for much less than the effects of splinters. 

Aneurisms are more frequent with the present- 
day jacketed bullets than formerly. The small en- 
trance and exit wounds make it more difficult for 
the blood to flow. Regarding treatment of haem- 
orrhage in the field the author states: In venous 
haemorrhage pressure bandages are usually sufficient. 
Ligation is rarely necessary. In arterial haemor- 
rhage in about half of the cases, ordinary means — 
elevation of parts, pressure bandage or tampon — 
suffice. Of 421 arterial haemorrhages only 201 
required ligation. 

When the firing is at close range death from 
haemorrhage is more common. Regarding aneu- 
risms, they rarely result from grenade splinter or 
shrapnel wounds which are likely to be fatal. They 
are rare in wounds from jacketed bullets with frac- 
ture of the large bones; they occur only occasionally 
when the entry and exit wounds are large. 

Secondary haemorrhages are even more important 
than primary. These may be the result of infection 
(septic erosion) , or a spicula of detached bone may 
injure the vessel, or it may be due to pressure of a 
drain in the vicinity of a vessel. It is not always 
noticed until the patient's condition is serious. If 
these secondary haemorrhages are frequently re- 
peated, amputation may be called for. If the 
secondary haemorrhage is from a main arterial 
trunk which is badly infected, amputation is the best 
course, as suturing and ligation is out of the question. 

The author has found vast benefit in parenchymat- 
ous septic secondary haemorrhage from intravenous 
injections of coagulen. 

With regard to internal haemorrhages, the author 
states that haematomata are usually present in all 
war injuries of the larger vessels. They show pulsa- 
tion. Where a vein is injured, arterial blood fre- 
quently finds its way directly into the vein causing 
an arteriovenous fistula and the formation of haema- 
toma is small. 

Diagnosis of hsematoma is usually easy, but it may 
be confounded with abscess. On account of the 
possibilities of perforation, infection or gangrene of 
haematoma, and the fact that spontaneous healing is 
infrequent, the author thinks active early surgical 
intervention is indicated. 

Kuettner treated altogether 93 aneurisms, 56 of 
these were complete and 37 were in the haematoma 
stage; 45 per cent were arterial; 55 per cent were 
arteriovenous; 73.6 per cent were treated by liga- 
tion; 26.4 per cent by suture. W. A. Brennan. 

POISONS 

Freeman, L. : Chronic General Infection with the 
Bacillus Pyocyaneus. Tr. Am. Surg. Ass., Wash- 
ington, 1916, May. 

The author gave a brief statement of the promi- 
nent symptoms of pyocyanic infection, together with 



the main facts in its pathology, and a somewhat 
detailed report of an instance of the more unusual 
chronic form of the disease, of which only a few cases 
have been recorded. 

The author's case was an adult, who had been ill 
for nearly eleven months. He had a high fever of 
the septic type, eruptions upon the skin, severe 
neuralgia, serous effusions, and muscular paresis 
and atrophy. 

During an exploratory laparotomy a cholecys- 
tostomy was done and a pure culture of the bacillus 
pyocyaneus recovered from the black and thickened 
bile. From this a vaccine was made and adminis- 
tered to the patient, following which the patient 
gradually recovered. 

The features of especial interest in the case are: 

1. Its extreme chronicity (nearly 11 months). 

2. The typical neuralgic pains, followed by pare- 
sis and muscular atrophy. 

3. The absence of the bacillus pyocyaneus from 
the blood and its presence in the bile. (The germ 
does not grow in the blood, but is merely conveyed 
by it, lodging and multiplying in the vessel walls. 
It is found mostly in the parenchymatous organs, 
such as the liver, spleen, and kidneys, hence is par- 
ticularly apt to infect the bile.) 

4. The absence of any discoverable point of in- 
fection, unless it might be the teeth. 

5. Recovery following drainage of the gall-blad- 
der and the use of an autogenous vaccine. 

6. The occurrence of cirrhosis of the liver. 

7. The presence of ascites and pleural effusion. 

8. The satisfactory recovery after so severe and 
protracted an illness, with the exception of a mod- 
erate paresis of the lower limbs, which seems to be 
improving. 

Barling, G.: Remarks on Delayed Tetanus. Brit. 

M. J., 1916, i, 337. 

Three cases are reported in which the incubation 
period varied from 50 to 53 days. In most of the 
cases the original wound had apparently healed 
before the onset of tetanus. The cause of the pro- 
longed incubation period is unknown, although 
several theories are advanced. At least two of the 
patients reported had prophylactic doses of anti- 
tetanic serum, which may have inhibited the 
growth of the organisms or neutralized all of the 
toxin available during the first days after the receipt 
of the wound. In several of the cases a lowering 
of resistance seemed to precede the onset of the 
tetanus. J. H. Skiles. 

Abercrombie, R. G.: The Treatment of Tetanus. 

Brit. M. J., 1916, i, 339. 

Four cases are reported in full. The effectual 
daily dose would appear to be 10,000 to 12,000 
units. This may be given twice a day in critical 
cases. The major portion of this dose should be 
given intravenously, subcutaneous injections being 
also used to maintain the effect. Intrathecal injec- 
tions should be given daily or at such intervals as 



GENERAL SURGERY — MISCELLANEOUS 



59 



the symptoms demand. The dosage must be 
reduced gradually in order to prevent relapse. 

All will agree as to the desirability of vigorous 
treatment of soiled wounds as a preventive of 
tetanus; but when once the disease has declared 
itself, operative surgical interference with the 
surface of the wound, although recommended by 
several authorities, is a proceeding accompanied 
by considerable danger. Protective inflammatory 
barriers would thus be broken down exposing the 
tissues to the tetanus toxin. J. H. Skiles. 

SURGICAL THERAPEUTICS 

McGuire, S. : The Post-Hospital Care of a Surgical 
Patient. South M. J., 1916, ix, 251. 

The author urges the formulating of plans 
whereby surgical patients leaving a hospital will 
have their post-operative treatment superintended 
by the surgeon in co-operation with the family 
physician. Patients are not immediately cured 
after operation, and they need varying lengths of 
time to return to normal after their disease has been 
rectified from a surgical standpoint. The patient 
cannot be trusted to safeguard his own interest 
during this time, for the knowledge of the laity 
on medical subjects often seems to be in inverse 
proportion to their intelligence and common sense 
in everyday matters. Correspondence between 
surgeons and patients is unsatisfactory because 
the patient usually fails to give important facts 
and often either overexaggerates or underestimates 
his symptoms. 

In the author's opinion the best results in following 
up post-operative cases will result from the co-oper- 
ative efforts of the surgeon, family physician, and 
patient. The plan he suggests is somewhat as follows : 

The patient, on leaving the hospital, is given a 
form covering the general points that will be of 
interest to him in his post-operative life with rela- 
tion to his definite operation. He is told to report 
to his family physician for tonics, hypnotics, and 
cathartics. A description of the operation and 
operative findings is sent to the physician and full 
explanation of the case is made to him so that he 
will be able to intelligently direct the patient in 
his post-operative care. 

The author finds that about 90 per cent of the 
ordinary hospital cases can be covered amply with 
regard to their post-operative care by instructions 
on about 12 different types of blanks, depending 
on the character of the operation. In about 10 
per cent of cases it is necessary to enlarge on these 
instructions personally. Harry G. Sloan. 

SURGICAL ANATOMY 

Wood, F. C, and McLean, E. H.: The Effect of 
Phloridzin on Tumors in Animals. J. Cancer 
Research, 1916, i, 49. 

Following the report of Benedict and Lewis in 
1914 of the cure of malignant tumors in rats by the 



induction of diabetes with phloridzin, the ex- 
periments here described were undertaken by the 
authors for the purpose of ascertaining to what ex- 
tent the results of Benedict and Lewis could be du- 
plicated in large series of animals bearing the tumor 
with which they had worked, as well as in animals 
bearing other types of neoplasms. 

The tumors used in these experiments were the 
Buffalo rat sarcoma, Crocker Fund sarcoma No. 
180, and seven spontaneous mammary carcinomata 
of mice. 

Among the mice bearing spontaneous tumors 
and Crocker Fund mouse sarcoma No. 180, they 
found no cases of absorption of the tumors under 
treatment. The slightly slower growth occurring 
in some of the treated animals bearing No. 180 
they believe cannot be considered as due to the 
treatment, as the difference was not so great as often 
occurs in untreated animals from the normal 
variability of growth of this tumor. Ulceration, 
which is also more frequent among the treated 
animals, probably on account of the poor nutrition 
of the host, must be considered, they state, as a 
factor when comparison is made between the size 
of the treated and of the control tumors. 

The Buffalo rat sarcoma showed a much smaller 
percentage of absorption among the treated animals 
than among the controls, 37 per cent as compared 
with 58.4 per cent, and in the majority of the ex- 
periments carried out by the authors the growth 
among the treated animals was much more vigorous 
than that among the controls. 

Considering the very great variability of growth 
of the Buffalo rat sarcoma, as well as the high per- 
centage of cases of spontaneous absorption occurring 
constantly, but with great irregularity, in different 
series of animals, the futility of using this tumor for 
therapeutic experiments or of basing conclusions 
upon such investigations, the authors believe, is at 
once evident, and any " cures " obtained in work with 
the Buffalo rat sarcoma must be ascribed to spon- 
taneous absorption rather than to the effect of the 
therapeutic agent, George E. Beilby. 

Uffreduzzi, O. : Contributions to the Experimental 
Surgery of the Mediastinum (Excluding the 
Heart). Am. Med., 1916, xxviii, 89. 

Uffreduzzi reviews the various methods of op- 
erating upon the mediastinum through the pleura 
and the various positive and negative pressure ap- 
paratus. He describes an apparatus which is a 
modification of the Meltzer-Auer apparatus which 
he believes has the advantage of preventing the 
reflex of ether in the respiratory tract and of per- 
mitting the use of oxygen instead of atmospheric 
air, and of being applicable even to a positive- 
pressure mask in case intubation should eventually 
fail or be contra-indicated. With the aid of this 
device the author has been able to perform a large 
series of experiments upon dogs in which extensive 
operations were performed upon the oesophagus, the 
thoracic aorta, the thoracic duct, the pulmonary 



6o 



INTERNATIONAL ABSTRACT OF SURGERY 




The elastometer. (Schwartz.) 

artery, superior and inferior venae cavae and the 
vagi and the intercostal nerves. 

With an experience of more than 300 narcoses in 
which the author has used this type of apparatus, 
he states that the method of narcosis is not only 
excellent but is attended with the lowest mortality 
of any method that can be applied to animals. 
He states that he has never had a death during the 
narcosis that could be ascribed to the method even 
when the anaesthetic was prolonged for several 
hours, that the opening of both pleura is perfectly 
tolerated, that post-operative pneumonia is very 
rare, and that with this method one is able to work 
with almost no respiratory movement. 

George E. Beilby. 

Schwartz, A. B.: The Clinical Study of (Edema 
by Means of the Elastometer. Arch. Int. Med., 
1916, xvii, 396. 

The elastometer, an instrument devised by Schade 
to measure oedema, the author believes promises to 
change the study of oedema from a subjective one 
depending on the amount of pitting obtained on 
pressure, to an objective one whereby the degree of 
oedema may be expressed in exact terms. The 
instrument which Schade has devised consists of a 
disk mounted on a perpendicular tactile rod which 
is placed on the skin surface, with the addition of a 
superimposed weight. The amount of depression 
caused by the sinking of the weighted disk into the 



skin and subcutaneous tissue is graphically trans- 
ferred by a writing lever to a revolving drum, making 
a characteristic curve. Surrounding this tactile 
disk, which measures the elasticity, is a set of three 
similar tactile disks, which rest on the surrounding 
skin surface, and indicate by a separate lever on 
the revolving drum any movement of the central 
disk other than that caused by the addition or re- 
moval of the weight. This line is known as the con- 
trol line, and must be straight in order to have the 
record of any value. Thus, faulty curves caused by 
disturbing factors can be eliminated by observing 
the control line. 

Schwartz believes that with the use of this instru- 
ment, the elastometer, the study of cedema will be- 
come a more accurate one, although he thinks that 
with the present instrument the expression of 
oedema in mathematical terms is not deemed ad- 
visable, but that the character of the curves, to- 
gether with the deficiency of return to the base line, 
would permit an approximate estimation of the 
intensity of an cedema. 

Furthermore, he states that the instrument makes 
possible the recognition of slight degrees of cedema 
which heretofore could not be detected. Persistent 
evidence of elasticity loss, despite the disappearance 
of other signs in patients with nephritis or endocardi- 
tis, Schwartz believes, indicates the advisability 
of more prolonged observation in cases of this charac- 
ter. George E. Beilby. 

Ewing, J.: Pathological Aspects of Some Problems 
of Experimental Cancer Research. J. Cancer 
Research, 1916, i, 71. 

The numerous experiments that have been con- 
ducted in this field seem to the author to point to 
the necessity of regarding all forms of neoplasms as 
specific diseases, connected only by the fact that they 
are neoplastic in greater or less degree, but differing 
in their etiology, clinical course, and therapeutic 
possibilities. The habit of regarding cancer as a 
protean disease of uniform significance, the author 
believes may well be abandoned in the interests 
of progress, and when cancer research properly oc- 
cupies itself in the study of the distinctive features 
of different cases of malignant disease, especially, 
he states, when it abandons the idea of a universal 
cure for cancer, it will be in accord with sound path- 
ological sense. It will then not be necessary, he 
thinks, to talk wisely to the public about the ob- 
scurities of cancer etiology, or to speculate about 
why cells grow lawlessly. Concerning the ultimate 
nature of neoplastic overgrowth, he says, we shall 
never have more than a descriptive knowledge. 

George E. Beilby. 

Haskins, H. D.: The Uric Acid Solvent Power of 
Urine After Administration of Piperazine, 
Lysidin, Lithium Carbonate, and Other Alka- 
lies. Arch. Int. Med., 1916, xvii, 405. 

In a recent paper Haskins reported the results of 
an investigation of the uric acid dissolving power of 



GENERAL SURGERY — MISCELLANEOUS 



6i 



hexamethylenamine. He showed that the mode of 
action of that drug was quite different from that 
of the rest of those substances which have been 
classed as "uric acid solvents." He states that 
these latter, if they act at all as solvents, do so by 
virtue of being basic substances. His purpose in 
this paper is to report an investigation of the solvent 
power of the most important members of this class. 
The organic compounds which he studied were 
piperazine and lysidin which are amine derivatives, 
and the nitrogen of their molecules imparts to these 
substances a basic character so that they combine 
with acids. These substances are supposed to 
form salts with uric acid which are very soluble. 
The other compounds which he studied were 
lithium carbonate, sodium citrate, and sodium 
bicarbonate, which are supposed to act as alkalies 
to uric acid forming lithium and sodium urates 
which are quite soluble. The conclusions which 
the author forms from his study are as follows: 

1. Piperazine can cause the urine to dissolve an 
increased amount of uric acid, and this effect is most 
marked if sodium citrate or bicarbonate be also 
given and if diuresis be avoided. 

2. Lysidin can act as a uric acid solvent but is 
not a practical therapeutic agent because of the large 
doses required. 

3. Lithium carbonate is a uric acid solvent if 
large enough doses are used, but is unsafe and pos- 
sesses no advantage over sodium citrate or bicar- 
bonate. 

4. Sodium citrate and bicarbonate are reliable 
and satisfactory uric acid dissolving agents when 
given in such dosage as to keep the urine alkaline. 

George E. Beilby. 

RADIOLOGY 

Bacmeister, A.: The Results of Combined Mer- 
cury-Lamp and Deep X-Ray Treatment of 
Human Lung Tuberculosis (Die Erfolge der 
Kombinierten Quarzlicht-Roentgentiefentherapie bei 
der menschlichen Lungentuberkulose) . Deutsche 
med. Wchnschr., 1916, xlii, 99. 

The favorable results obtained in deep X-ray 
treatment of experimentally produced tuberculosis 
of the lung in animals have justified the extension of 
this method to the human subject. Kuepferle has 
recently reported on 44 cases in different stages 
treated by deep X-ray. In 19 cases in the first 
stages he got good results; he also got good results 
in 14 partly disseminated partly confluent cases; 
no permanent improvement was observed in 11 
cases in the third stage. 

Bacmeister 's experience is confined to 20 cases of 
stationary to latent phthisis, subjected to one 
month's treatment. In 9 of these all symptoms 
have disappeared and in the others there were 
good results. 

In a second group with fever, and with chronic 
progressive symptoms, but without caseous exudate, 
he counts 10 clinically cured patients. Of 23 patients 



of this group in which there was no complete cure, 
19 have been much improved. 

Bachmeister abstains from the treatment of 
patients with high fever and rapidly progressive 
symptoms. As in the case of animals Bachmeister 
thinks that the good effects of the X-ray treatment 
is not due to any effect on the bacillus, but to the 
effect on the granulation tissue which is destroyed 
and replaced by cicatricial tissue. He thinks that 
combined with hygienic measures roentgen therapy 
combined with mercury-lamp treatment of lung 
tuberculosis has proved itself a valuable method in 
the limited number of cases in which it has been 
applied. W. A. Brennan. 

Kuepferle and Bacmeister: Experimental Grounds 
for Treatment of Lung Tuberculosis by X-Rays 

(Experimentelle Grundlagen fuer die Behandlung 
der Lungentuberkulose mit Rontgenstrahlen). 
Deutsche med. Wchnschr., 19 16, xlii, 96. 

The authors instituted a series of experiments to 
determine the effect of hard filtered X-rays on 
experimentally produced lung tuberculosis in rab- 
bits. The conclusions which they draw from these 
experiments are that a beginning experiniental 
tuberculosis of the lungs may be suppressed, and 
an established tuberculosis may be healed. 

The effect of the raying is to transform rapidly 
growing tuberculous granulation tissue into cicatri- 
cial tissue. It has no effect on the tubercle bacillus. 

Small doses of rays at long intervals have little 
effect; very large dosage, without suflftciently long 
reaction intervals, may give rise to bronchitis and 
bronchopneumonia. 

In animals a dosage of 20 to 23 at 3 to 5-day 
intervals effected healing. The mercury-lamp had 
no direct influence on lung tuberculosis. 

On the basis of their experimental findings, the 
authors have introduced X-ray therapy for lung 
tuberculosis in the Freiburg Medical Klinic. 

W. A. Brennan. 

Hammes and Schoepf: Exact Localization of 
Foreign Bodies by Means of Roentgen Rays 

(Zur genanen Localization von Fremdkoerpern 
mittels Roentgenstrahlen) . Deutsche med. Wchnschr. , 
1916, xlii, 252. 

The authors describe the technical details of an 
apparatus to put into practice results obtained from 
certain mathematical equations which give the 
position of a foreign body located in the body. They 
claim that location can be obtained in a few minutes 
and that probably their method is superior to the 
many procedures described by others. 

W. A. Brennan. 

Wintz, H. and Baumeister, L. : The Proper Filter 
for Deep Roentgen Therapy (Das zweckmaessige 
Filter der Roentgentiefentherapie). Muenchen med. 
Wchnschr., 1916, Ixiii, 189. 

The authors made a series of experiments to 
determine what was the best material and most 



62 



INTERNATIONAL ABSTRACT OF SURGERY 



suitable thickness of a filter for deep roentgen 
treatments. Experimentation with various metals 
showed that the most favorable results were ob- 
tained with an aluminum filter 3 mm. thick and 
with a zinc filter o. 5 mm. thick. 

To obtain an equal dosage on the skin with alu- 
minum and zinc filters the exposure in the case of 
zinc must be three to three and one-half times as 
long as with aluminum; but at a depth of 8 to 10 cm. 
the ratio is reduced to i :2. At this depth when using 
the thicker zinc filter by doubling the strength of 
the rays, the same dose can be received on the skin 
as with the thinner aluminum filter. The advan- 
tage is that a dosage which with an aluminum filter 
would reach the erythema limit may be doubled by 
using a zinc filter. The authors prefer the zinc filter 
to any other. W. A. Brennan. 

Case, J. T.: Roentgen Treatment of Deep-seated 
Cancer. Physician &° Surg., 1915, xxxvii, 442. 

Case states that in general it must be admitted 
that the X-ray treatment of deep-seated carcinoma 
has not up to the present time gratified the fond 
hope with which the discovery of this method was 
so fervently greeted. 

In superficial carcinoma where there is deep 
ulceration with involvement of the neighboring 
glands, etc., a very thorough-going preliminary pre- 
operative roentgenization should be administered. 
On the ninth or tenth day a radical operation should 
be performed followed later by another X-ray treat- 
ment. By combining roentgenization with surgical 
intervention one is most likely to insure good results. 

Discussing the question as to whether operable 
carcinoma shall be treated by irradiation or opera- 
tion, Case states that the results which have thus 
far followed roentgentherapy of deep-seated malig- 
nant affections do not warrant the belief that 
roentgentherapy affords a means of cure in these 
deep-seated lesions. In the light of our present 
knowledge it may be stated as an axiom that the 
X-ray method should never replace or in any way 
interfere with the surgical treatment of cancer. 

In looking over the literature of competent 
authors it is seen that in about 25 to 30 per cent of 
the cases of uterine carcinoma, the results of roent- 
gentherapy are very satisfactory from a palliative 
standpoint; but as yet Case has not seen an instance 
of definitely proven cure of pelvic cancer following 
the application of roentgentherapy. 

In mammary carcinoma good palliative results 
are nearly always the rule. 

The good palliative results which have followed 
the X-ray treatment of recurrences and inoperable 
cases warrant the adoption of post-operative 
X-ray treatment as a routine in malignant cases. 

The treatment should be applied as soon as 
possible after operation and as thoroughly as though 
the disease was still present in its entirety. 

Case's technique in operable cases is to submit 
the patient eight or ten days before operation to 
cross-fire filtered rays in full dose in as many areas 



as possible. Ten days after operation the patient 
is again submitted to a further series of treatments 
administered as though the tumor were still present. 

HoLLis E. Potter. 

Hanford, C. W.: Some Radium Physics. Chicago 
M . Recorder, 1916, xxxviii, 143. 

The author states that the high aim of the radio- 
therapist should be to direct the radium rays to 
the deep tissues where the disease is located, with 
the least injury to the healthy structures; and that 
in many instances where results have not been 
obtained from their application, failure may be 
traced to a lack of knowledge of certain physical 
facts that had not been observed by the operator. 
A number of examples are given, such as where 
a tube of radium has been used supposed to con- 
tain a given amount of radium element, is tested 
after repeated failure, and found to contain only a 
very small amount, entirely inadequate for the 
purpose. Methods are reviewed which if carefully 
observed will save the operator from such errors. 

W. S. Newcomet. 

Wood, F. C, and Prime, F., Jr.: The Action of 
Radium on Transplanted Tumors of Animals. 

Ann. Surg., Phila., 1915, Ixii, 751. 

The opinions, based chiefly on clinical reports, 
of the therapeutic value of radium in the treatment 
of malignant growths have differed greatly. 
Whether the ^- or the 7- rays are the most efficient 
in treating tumors, or whether both should be 
employed, are questions still undecided. For these 
and other reasons, the authors carried out a number 
of experiments in the Columbia University to deter- 
mine the biologic action of radium, using animal 
tumors as an index of the lethal effect. Rat and 
mouse tumors of various types were used, among 
them the Ehrlich spindle-cell mouse sarcoma, and 
the Flexner-Jobling rat carcinoma. They were 
treated either after removal from the host or in situ, 
strict asepsis being observed. After exposure to 
the /3- and 7- rays, portions of the treated tumor, as 
well as untreated fragments, were inoculated with 
animals of the same strain. A-rays were not used. 

These results are claimed by the authors from 
their experiments: 

1. Three factors only are important in the action 
of radium on tumors: time of exposure, amount of 
the radium element, and distance between the radi- 
um tube and the tumor tissue. 

2. The removal of the /3-rays diminishes the 
effect of the radium, but the effect of the 7- rays is 
in accordance with the same general law which 
governs the /3-rays. 

3. Sublethal exposures hinder the growth of 
tumor cells for some time, while still shorter treat- 
ments seem to stimulate the cellular activities. 

4. The facts derived from the experiments regard- 
ing the quantity of radium element and the time of 
exposure necessary for a given distance may be 
applied, with reasonable accuracy, to human malig- 



GENERAL SURGERY — MISCELLANEOUS 



63 



nant tumors. These experiments show that when 
only pure 7-rays are used the necessary exposure is 
eight times as long as that required when the 7- 
and hard /3-rays combined are employed; but as 
the latter are largely absorbed by i cm. of tissue, the 
7-rays alone must be used for all deep work. 

5. The effect of radium radiations on tumor-cells 
in vitro is less marked than on isolated cellular ele- 
ments. This explains the fact that an exposure 
which will destroy a small metastatic nodule in man 
is quite ineffective in the case of a well vascularized 
primary carcinoma. Hollis E. Potter. 

Ouigley, D. T.: Therapeutic Effects of Radium. 

J.-Lancet, 1915, xxxv, 653. 

Quigley thinks that in ordinary cases of cancer, 
such as cancer of the breast, etc., the best plan is 
to operate when operation is possible and use 
radium as an after-treatment to kill out such cells 
as may be missed by the knife and thereby lessen 
the chances for recurrence. He believes the great 
future for radium is as a post-operative treatment. 
The question with relation to radium in cancer is 
not. Will radium supplant surgery in these cases? 
but. Will our surgical results be bettered by using 
radium in conjunction with surgery? 

HoLLis E. Potter. 

McConnell, A. A. : A New Medium for Pyelography. 

Med. Press 6* Circ, 1916, ci, 238. 

For some years coUargol, a colloidal silver prepara- 
tion, has been the medium most used for pyelog- 
raphy, and although other substances have been 
tried, as iodide of silver, none have proved so gen- 
erally satisfactory. 

Since the war, however, coUargol has become 
most unprocurable, and McConnell in seeking a 
substitute in the English and American markets, 
failed to find anything but silver iodide, which, 
in his hands, did not give as satisfactory results. 
He therefore consulted Professor Caldwell of the 
Royal College of Surgeons, Ireland, asking him for 
a salt opaque to X-rays, harmless to the kidney, 
and capable of being injected through a ureteral 
catheter. Professor Caldwell was able to meet 
this request and supplied him with an entirely new 
bismuth compound to which the provisional 
name skirol is given. This is a non-irritating sub- 
stance, has the consistency of milk, and is washed 
out of the renal pelvis by the urine before precipita- 
tion takes place. McConnell uses a 10 per cent 
solution, and has obtained better pictures than any 
he has obtained with coUargol. It has not caused 
irritation in any of his patients. Moreover, he 
found that it disappeared from the pelvis more 
rapidly than coUargol. CoUargol has been found 
to remain in the renal pelvis from one to several 
weeks, while in some cases in which skirol was used, 
radiographs taken one or two days after the injec- 
tion showed no shadow. 

The technique is as f oUows : The patient is placed 
on the roentgen table, tl^e ureteral catheter is 



introduced up to the renal pelvis, the X-ray plate 
is adjusted, and preparations made to take a pic- 
ture. The skirol solution is then allowed to flow 
into the ureteral catheter by gravity, from a con- 
tainer which is held not more than 12 inches above 
the level of the kidney, until the patient announces 
that some pain is felt in the kidney. At that in- 
stant the injection is stopped and the roentgeno- 
gram is taken. Then the fluid is allowed to run 
out and the catheter is removed. 

DAvro C. Straus. 

MILITARY SURGERY 

Mott, F. W. : The Effects of High Explosives upon 
the Central Nervous System. Lancet, Lond., 
1916, cxc, 331. 

The author describes three groups of cases in 
which the nervous system was injured by explosives: 
(i) immediate death from a missile; (2) injuries 
from high explosives which cause wounds, but are 
not fatal; (3) injuries of the central nervous system 
without visible injury. To the latter group must be 
added those cases which develop functional neuroses 
and psychoses. 

The third group of cases is the one specially dealt 
with in this paper. Several theories are elaborated 
as to the possible causation of these intangible 
injuries to the nervous system: (i) Increased 
pressure in the cerebrospinal fluid may be the causa- 
tive factor in these injuries. (2) Nerve-cells in a 
state of exhaustion are much more susceptible to 
shock than nerve-cells in the normal state. This 
fact may account for sudden death from the explo- 
sion of a shell without physical injury. (3) The 
sudden change in atmospheric pressure brought 
about by the explosion of a shell may result in the 
freeing of gas bubbles in the nervous tissues causing 
a similar condition to that found in caisson disease. 

These theories are merely advanced by the author 
in a preliminary way and the discussion is to be 
continued. J. H. Skiles. 

Vincent, B., and Greenough, R. B.: Gunshot 
Wounds of the Soft Parts. Boston M. drS. J., 
1916, clxxiv, 153. 

Vincent and Greenough at the American Ambu- 
lance, at Neuilly-sur-Seine, report 318 cases of 
injuries of soft parts by missUes such as shrapnel 
balls, rifle bullets, or shell fragments. The wounds 
were of every kind : lacerated penetrating, perforat- 
ing, or wide surface abrasions. When received at 
the American Ambulance a majority of the cases 
were from twenty-four to seventy-two hours old 
and were with few exceptions septic. On entering 
the hospital the patient was given a general anaes- 
thetic. The operation was devoted primarily to 
cleaning the wound and making free drainage. 
The wounds were enlarged as much as the extent 
of the infection required. The crushed edges of the 
wound and aU the necrotic tissue were excised. 
All foreign material was removed. While no par- 



64 



INTERNATIONAL ABSTRACT OF SURGERY 



ticular search was made at this time for missiles, 
for fear of spreading the infection to uncontaminated 
tissues, they were often discovered and removed. 
Pieces of clothing were often found just beyond or 
wrapped around the missile. When pieces remained 
in the tissues the course of sepsis was always pro- 
longed. The use of rubber tissue for wicks and as a 
protective covering for raw surfaces prevented the 
gauze dressings from adhering to the wounds and 
saved the patients much suffering. Some of the 
most septic wounds were given continuous irriga- 
tions of sodium-hypochlorite solution, others had 
wet dressings that were frequently changed. Sec- 
ondary sutures were done with good results in cases 
with extensive granulating surfaces. 

The means of localization most frequently em- 
ployed were the fluoroscope, X-ray plates, and the 
Bergonier electromagnet. The magnet was operated 
with an alternating current in such a way that the 
shell fragment was put into rapid vibration. By 
placing a hand on the skin between the magnet and 
the foreign body the place of maximum vibration 
was noted and an incision made at that point. The 
method could be applied to missiles in the soft parts 
only and not too distant from the skin. The extrac- 
tion of a missile was often facilitated by the use of an 
ordinary electromagnet. A metal probe with its 
outer end resting against the magnet was inserted 
into the wound till it touched the piece of metal. 
The magnetized probe would in turn attract the 
missile which was withdrawn with the probe from 
the wound. ■ This method was employed success- 
fully by Gushing in removing fragments of shell 
from the brain and by Blake on a piece of shell 
buried deep in the pleural cavity. 

For routine work the fluoroscope proved the most 
rapid, accurate, and economical means of localizing 
lodged missiles. 

In certain cases where the fragments were small 
and numerous or because of an absence of symp- 
toms, the missiles were left in situ. A. H. Hixson. 

Weinberg, M.: Bacteriological and Experimental 
Research on Gas Gangrene. Lancet, Lond., 
1916, cxc, 622. 

The work reported was first undertaken in the 
British Hospital at Versailles, September, 19 14, during 
the battle of the Marne, and was conducted later 
in a number of hospitals, both French and British. 
The majority of surgeons seemed to have a confused 
idea of the nature of gas gangrene at the beginning 
of the war, and the tendency seemed to be to diag- 
nose the condition every time a bad wound became 
infiltrated rapidly with gas. Two forms of gas 
gangrene are described: (i) the classic and (2) the 
toxic form. 

In describing the classic form the author gives 
the details of a case as follows: A soldier was ad- 
mitted to the hospital twenty-four hours after 
being wounded. The foot and two-thirds of the 
leg were very much discolored; the discharge emitted 
a putrid odor. The leg and thigh were swollen as 



far as the junction of the middle and upper third; 
the veins were distended; the skin bronzed; and 
there was crepitation on palpation around the 
wound. The temperature was 102.5° F. A few 
hours later crepitation extended over the entire 
leg and thigh, and large blebs containing dark fluid 
were scattered here and there on the surface. 
The temperature rose to 104° F. Amputation was 
done in the middle of the thigh; the gangrene spread 
to the body and neck, and death occurred at the 
end of the second day. Dyspnoea was marked two 
hours before the end. 

The development of some cases of this classical 
form was not always as rapid as in the foregoing 
case, because the microbe chiefly answerable was of 
a low degree of pathogenicity, and in such mild 
cases radical surgery often saved the patient. 

The toxic form is characterized by extensive 
oedema, sufficient in some cases to mask the gas in- 
filtration. This form is illustrated by the follow- 
ing case: A patient was admitted to a French 
hospital forty hours after he was wounded, having 
been exposed twenty-four hours between the French 
and German lines after the receipt of the injury. 
There was a wound in the middle third of the fore- 
arm. Gas crepitation around the wound was 
slight but extensive oedema was present up to the 
middle of the arm and the veins were prominent. 
In spite of free incisions and irrigation with oxygen 
peroxide, the oedema extended to the shoulder 
and chest and death occurred twenty-four hours 
later without the appearance of much crepitation. 
There was a putrid odor which was not necessarily 
a symptom of the case and it bore no relation to its 
gravity, since it might have been due to organisms 
of a low pathogenesis which were present. 

The author exhibited some microphotographs of 
culture fields from cases which showed a variety 
of organisms, including bacilli perfringens, staphy- 
lococci, streptococci, and diplococci; also bacillus 
sporogenes. 

It seemed that gas gangrene was not due to any 
one specific micro-organism. There is great dif- 
ficulty in distinguishing bacillus perfringens from 
vibrion septique (malignant oedema), and the toxins 
must be tested with antitoxic serum. Bacillus 
perfrigens produces a large quantity of gas while 
vibrion septique produces less. A bacillus cedematis 
had also been found in some cases, the toxins from 
which, when injected subcutaneously in guinea pigs, 
produced a rapidly extending oedema. This microbe 
was frequently associated with bacilli sporogenes. 
Weinberg emphasizes his belief that there is no 
flora peculiar to gas gangrene. A new microbe, 
bacillus fallax, causing gas gangrene has lately been 
discovered, when and by whom is not stated. Some 
of the organisms found in the flora of gas gangrene 
emanate from the air, others are of intestinal origin. 
Attempts to make haemocultures have not been suc- 
cessful and they were rarely positive in the septic 
form of the disease. The very rapid course of 
gas gangrene in men and animals is thought to be 



GENERAL SURGERY — MISCELLANEOUS 



65 



due to individual susceptibility. Careful observa- 
tion and experiment have shown that gangrene of a 
limb is not always the result of gas-producing organ- 
isms, but complete obliteration of the vessel may 
arise from non-gas-producing organisms. It is 
interesting to note that gangrene of a limb following 
stoppage of the blood supply affords favorable con- 
ditions for the growth of gas-producing microbes. 
To prevent gas gangrene, wounds should be 
treated early and radically. The diminution in 
the number of cases occurring now, as compared to 
the earlier period of the war, is due to the well- 
developed transport facilities which enable the 
relief corps to remove the wounded from the fight- 
ing front to casualty hospitals in a few hours. The 
wounds should be opened as widely as possible at 
once. Large projectiles and particles of clothing 
having been removed, the wound should be irrigated 
with weak antiseptics and the irrigation should be 
often repeated. Good results are also obtained by 
the use of superheated air and intravenous injec- 
tions of salvarsan. Injection of polyvalent serum, 
made from all the organisms concerned, was also 
considered helpful. 

Moynihan, B.: The Treatment of Gunshot 
Wounds. Brit. M. J., 1916, i, 333. 

The treatment of gunshot wounds in the present 
war has become greatly complicated by several 
factors: (i) The wounded soldier usually lies for 
many hours or even days before he can be removed 
to the field hospital. (2) The modern high-velocity 
projectile causes explosive destruction of tissue 
resulting in a large, deep, ragged wound, which is 
always infected. (3) The battlefields have been so 
intensely cultivated that the ground contains many 
virulent organisms with which the bodies and cloth- 
ing of the men are sure to become contaminated. 
(4) The hygiene of the soldier is necessarily very 
poor. In some instances clothing has been worn 
continuously for several months. This results in a 
filthy condition of the person, which, together with 
his general run down condition, naturally leads to 
contamination of the wound. 

The treatment of a wound therefore usually has 
to do with the combating of infection. A wound 
which is treated early may be excised or treated 
with some strong antiseptic, but these early wounds 
are in the minority. 

The treatment of an infected wound should be 
very thorough, the entire field being thoroughly 
cleansed and adequate drainage secured. Many 
antiseptic solutions have been tried, the one which 
has given the most satisfactory results being Dakins' 
solution. Dakins' solution is made from bleaching 
powder forming calcium hypochlorite. It is a very 
effective antiseptic and does not apparently injure 
the tissues. Continuous application of the fluid to 
the wound is secured by continuous irrigation or by 
keeping gauze wicks soaked by immersing the ends in 
a dish of the solution. Sufficient drainage should 
be insured. 



No gauze dressings or impermeable material 
should be placed over the wound, as a close covering 
tends to dam up the secretion. 

The hypotonic salt solution of Wright is highly 
recommended to induce lymph lavage. Morrison 
and TuUock have advised the use of a solution of 
magnesium sulphate in place of sodium chloride. 
Out-door treatment and plenty of fresh air often 
work wonders in hastening the recovery. 

The use of vaccines is still a matter of controversy, 
but there are undoubtedly selected cases in which 
they do much good. J. H. Skiles. 

Carrel, Dehelly, and Dumas: Secondary Closing 
of Wounds. Brit. M. J., 1916, i, 211. 

The authors presented a paper at the Paris 
Academy of Medicine in January on the results of 
the early closing of war wounds that have been 
treated with the sodium hypochlorite solution pre- 
pared after the Dakin formula. They conclude 
that the secondary closure of wounds in from four 
to ten days is a general method of great value. 

Free incision of wounds as done formerly for 
exploration, the removal of foreign matter, and the 
use of drainage act as a drawback, since they prolong 
the treatment and cause an undue amount of 
cicatrization. The latter fills the spaces between 
the muscles, aponeurosis, and skin, which ends in 
adhesions and contractions, thereby hindering func- 
tion. To avoid this, treatment by the Dakin solu- 
tion permits the surgeon to bring the anatomical 
surfaces of a wound together by layers in the sec- 
ondary closing of the wound, just as he does in a 
primary operation. When brought together early, 
connective tissue has not had time to form unduly; 
it is reduced to a thin sheet which does not seriously 
interfere with muscular movements. 

The authors open up all wounds primarily, enough 
to admit of careful exploration, cleansing, and 
haemostasis. The hypochlorite solution is instilled 
constantly for several days by the technique already 
recommended by them in previous reports. As 
soon as the daily bacteriological examinations in- 
dicate the disappearance of bacteria the wound is 
closed, usually in four to ten days. In those 
wounds that remain uninfected the tissues are un- 
altered in the course of the antiseptic treatment, 
and the authors find that the wounds thus treated 
unite by first intention, as is observed in operative 
wounds. The tissues should always be brought into 
exact apposition with adhesive strips 2.5 to 5 cm. 
broad. If the skin becomes adherent to the sub- 
jacent structures and granulation tissue has filled 
the intervening space the skin is loosened from the 
edges of the wound, the granulations curetted, and 
the parts including the skin are then brought into 
apposition with sutures. This procedure hastens the 
rate of recovery, avoids stiffness and atrophic changes. 

M. Quenu and M. Bazy believe that good surgical 
technique and irrigation are of more importance 
than the employment of sodium hypochlorite as an 
antiseptic. L. A. LaGarde. 



66 



INTERNATIONAL ABSTRACT OF SURGERY 



B^rard, L., and Lumiere, A.: Some Elementary 
Rules Relative to the Treatment of Suppurat- 
ing Wounds in War (Quelques preceptes elemen- 
taires relatifs au traitement des plaies de guerre 
suppur6es). Rev. de chir., 1916, xxxiv, 445. 

The authors call attention to the difference in 
the condition of projectile wounds in the recent 
period of the European campaign, where the fight- 
ing was in the trenches, and that of the early period 
when the war was one of movement and projectile 
wounds were mostly uninfected. 

The suggestions which the authors formulate in 
the care and treatment of suppurating wounds are: 
(i) the removal as quickly as possible of all foreign 
bodies; (2) the draining as early as possible of in- 
fected tracts, and the discharging of purulent 
collections by large incisions and very large drains; 
(3) the treating of all wounds antiseptically, using 
hypochlorites preferably, especially the mixture of 
chloride of lime and boric acid; (4) the frequent 
changing of dressings and preventing the adhesion 
of pieces of the dressings to the wounds; (5) never 
to uselessly injure wounds; (5) to use humid dress- 
ings only occasionally in particular cases, renewing 
them quite frequently. A. Goss. 

Dalton, F. J. "A.: Sodium Hypochlorite in the 
Treatment of Septic Wounds. Brit. M. J., 
1916, i, 126. 

Dalton on the British hospital ship Rewa, in- 
vestigating the value of sodium hypochlorite in the 
treatment of septic wounds, reports a series of 57 
cases. The results obtained were uniformly excel- 
lent, and there was an absolute unanimity among the 
members of the medical staff in the hospital ship 
in the preference for hypochlorite solution in the 
irrigation of infected wounds. Wounds were en- 
larged, counteropenings made, bone fragments and 
foreign bodies removed, etc., and thorough irrigation 
instituted with large quantities of hypochlorite 
solution. Rubber tubes were then inserted, and 
gauze strips packed into all p.arts of the wound. 
The ends of the rubber tubes were brought out 
through the dressings that the hypochlorite solution 
might subsequently be renewed by means of a 
syringe. Fresh hypochlorite solution was applied in 
this way every two hours in the severe cases. In 
the worst cases the gauze strips were removed after 
twenty-four hours, in slight wounds they were left 
in three or four days, the wounds cleaning up with 
simply spraying fresh solution into the tubes. 

Dalton points out the following advantages ob- 
served in the employment of the sodium hypochlorite 
solution when properly prepared according to the 
Dakin formula: (i) The simplicity and cheapness of 
preparation of the antiseptic. (2) Being non-toxic 
and non-irritating to the tissues it may be used with- 
out ill effects in large quantities over long periods 
of time. (3) The deodorant action of the solution 
is remarkable. (4) The rapidity with which sloughs 
separate and clean granulation tissue is formed. 
(5) The infrequency of dressing required. (6) The 



fact that injections of the hypochlorite solution into 
the rubber tubes used in the dressings may with 
safety be entrusted to very imperfectly trained or- 
derlies without fear of ill results, once the case has 
been adequately dealt with by the surgeon. 

A. H. HixsoN. 

Health of Armies in Peace and War. Lancet, Lond., 
1916, cxc, 517. 

The annual report of the Surgeon General, U. S. 
A., for 1 914 gives us a valuable means of comparing 
the health of an army during peace with that of the 
armies at war in Europe. Although the army is 
small in comparison with the armies engaged in the 
gigantic struggle abroad, it is sufl&ciently large to 
give valuable data. 

Of the 88,000 men, 41 died of tuberculosis, 15 
each from pneumonia and chronic heart disease, 
10 from cancer — ratios which correspond with those 
of other armies during years of peace. The in- 
fluence of vaccination against smallpox and typhoid 
fever is well shown. Among the 88,000 men there 
were 7 cases of smallpox, with one death, and 3 
cases of typhoid fever, with no death. 

The principal causes of admission to sick report 
were alcoholism and venereal disease, although these 
are showing a marked diminution in the last 
decade. 

The Paris correspondent of the Lancet in a recent 
letter writes on the sick-rate of the French army 
at the front and shows that the more serious infec- 
tious diseases of civil life, such as scarlet fever and 
diphtheria, as well as mumps and less important 
ailments, are not so prevalent in the French army 
as during peace. Typhoid has been more frequent, 
but less fatal. No reference is made to the various 
special ailments of the present war — shell shock, 
soldier's heart, trench foot — and they may be 
intentionally omitted. The inference seems to be 
justified that the health of the French army has not 
been adversely influenced by the act of campaigning. 
Doctor Mosse of Berlin, author of a well-known 
work on disease and social position, has recently 
pointed out that diabetes mellitus and acute nephri- 
tis, often of the haemorrhagic form, are more fre- 
quent in the youthful combatants. The health of 
armies in peace and war has been conserved by the 
rules of sanitary science in all civilized countries. 
The devastations incident to cholera, cerebrospinal 
meningitis, typhus, typhoid, yellow fever, and 
malaria are now practically unknown. The sanitary 
service of the military establishments today is 
rendered efficient by drilling the medical personnel 
in the duties of health officers. It is easier and less 
expensive to prevent disease than to treat it or to 
arrest its spread. In this regard the Sanitary 
Service of the British Army has accomplished a great 
deal in the present war. Every division of the 
army has a sanitary section consisting of 26 men 
(not including army service corps men); viz., one 
officer and 25 non-commissioned officers and men. 
The officer is generally a medical officer of health 



GENERAL SURGERY — MISCELLANEOUS 



67 



or one who holds a diploma in public health service 
or as a bacteriologist; some are sanitary engineers 
and even architects. 

A large number of the non-commissioned officers 
are sanitary inspectors, some hold sanitary diplomas, 
others are plumbers, carpenters, schoolmasters, 
graduates in honors from Oxford, Cambridge, and 
other universities, solicitors, chemists, and represen- 
tatives of all professions and trades. In this varied 
personnel it is not difficult to provide each section 
with a sufficient number of disinfectors, interpreters, 
carpenters, cooks, builders for the special and varied 
services in the field. The work performed by these 
sections includes the bathing of troops by thousands; 
disinfection of the men for vermin, after enteric, 
cerebrospinal fever and other infectious diseases. 
Their further duties embrace disinfection of all 
clothing and blankets; purification of water; the 
drainage of farms and billets; giving instruction for 
the erection of destructors or incinerators, ablution 
tanks, grease traps, urine pits, filters, fly-traps, and 
the installation of every kind of structure or ap- 
pliance that appertains to sanitation in the field. 

After great battles, when the casualties are so 
great in numbers that the ambulances cannot deal 
with them, the personnel of the sanitary companies 
is called upon to assist in the care of the injured. 
This body of expert workers has rendered the Royal 
Army Medical Corps officers valuable assistance 
in many ways, especially in watching over the health 
and sanitation of the soldiers. 

Aside from the work of the medical corps and 
sanitary sections in warding off disease, great assis- 
tance has been derived from auxiliary bodies like 
the Red Cross. Through its assistance the mortal- 
ity among the wounded has been very much re- 
duced since its organization by Henri Dunant a 
half century ago. L. A. LaGarde. 

SURGICAL PATHOLOGY 

Razetti, L.: Operative Mortality (La mortalidad 
operatoria). Gac. med. de Caracas, 1916, xxiii, 17. 

The author reports the results of 310 operations 
performed during a period of 2 2 months. The cases 
were divided into the following groups: head, neck, 
thorax, abdomen, genito-urinary apparatus, perineum 
and rectum, extremities. 

Of 310 patients operated upon, 30 died, a mortality 
of 6.67 percent. The general mortality in the surgical 
clinic was divided into two classes: the pathological 
mortality and the operatory mortality, or those due 
to accidents or complications derived directly from 
the operation itself. 

Of the 30 deaths, 16 were pathologic and 14 opera- 
tory, or a pathologic mortality of 5.16 per cent 
and an operatory mortality of 4.51 per cent. 

The cases occurred in a general hospital; the cases 
were not selected, and some of the cases were in an 
advanced stage or their general condition on ad- 
mission was very unsatisfactory. 

Raoul L. Vioran. 



Apert, E,: Urticaria and Pseudo- Appendicitis. 

Monde med., 1916, xxvi, 65. 

The acute forms of urticaria and sometimes also 
the chronic, may give rise to an actual pseudo- 
peritoneal syndrome, akin to that of purpura and 
polymorphous erythema, possibly simulating appen- 
dicitis. Our present knowledge of the pathogenesis 
of urticaria enables us to understand what happens 
in such cases. 

Since the works of Richet, Artus, Lesne, Widal, 
and Joltrain, it has been known that urticaria is an 
anaphylactic phenomenon and that the cutaneous 
troubles are only the outward and visible manifesta- 
tions of sudden changes in the blood, of what Widal 
calls a "hsemoclasic crisis," of a splitting up of the 
blood. The pseudoperitoneal phenomena testify to 
the existence of this state. The absence of the 
local signs of acute appendicitis, the absence of rig- 
idity of the abdominal wall and of localized skin 
hyperasthesia , should prevent any confusion be- 
tween an attack of appendicitis and the pseudo- 
peritoneal attack associated with urticaria. 

W. A. Brennan. 

Gaucher: Unrecognized Syphilitic Lesions Sur- 
gically Operated as Cancers or as Local Tuber- 
culosis (Des lesions syphilitiques mecounues 
operees cirurgicalement comma cancers ou comma 
tuberculoses locales). Ann. d. mal. ven., Par., 
1916, xi, 153. 

Theoretically the differences between syphilitic, 
tuberculous, and cancerous lesions appear to be so 
well established that in practice there should hardly 
be an error. Nevertheless the diagnosis is some- 
times very difficult, or at least it is very inexactly 
made in a number of cases by surgeons who are 
experienced and well-informed. Errors are oftenest 
observed in chancres, gummatous infiltrations, and 
in osseous and articulatory lesions. 

The confusion of syphilis with local tuberculosis 
has very grave consequences, particularly when it is 
a question of osseous or articulatory lesions. The 
author has frequently directed attention to the 
similarity of the suppurative osteitis and the 
osteo-arthritis of hereditary tertiary syphilis and 
tuberculous osteitis and arthropathies. Suppura- 
tion is not and cannot be admitted to be a distinct 
characteristic of tuberculosis. Hereditary osseous 
syphilis can be suppurative as well as osseous tuber- 
culosis. 

Not alone in the matter of hereditary syphilis are 
errors made, but also in the white tumors in adults, 
which result from acquired syphilis and which are 
frequently treated as white tuberculous tumors and 
operated as such. 

The author mentions several cases which have 
come under his notice which corroborate his con- 
tentions. He therefore thinks that in all osseous or 
articular lesions which are apparently of tuberculous 
origin the Wassermann reaction should be looked 
for and mercurial treatment tried before surgery is 
resorted to. W. A. Brennan. 



INTERNATIONAL ABSTRACT OF SURGERY 



HOSPITAL, MEDICOLEGAL, AND MEDICAL 
EDUCATION 

The Duties of Medical Practitioners in Cases of 
Criminal Abortion. Bril. M. J., 1916, i, 206. 

The duties of medical practitioners in cases of 
criminal abortions are discussed in the original 
article. The question as to how far a medical 
man, who obtains in his professional capacity- 
knowledge of the commission of a criminal offence, is 
in duty bound as a citizen to give information to the 
police authorities and so set the criminal law in 
action, is one which should be of great interest to 
the medical profession. 

Probably the most frequent occurrence in which 
an opportunity of this kind might arise, is that of a 
medical man called in to attend a woman upon whom 
an illegal operation has been- performed; and in such 
a case under the decisions of the English Court cited 
in the article, it is safe to say. that the doctor is 
under no obligation to, and indeed should not, 
divulge the information which he has obtained in 
his professional capacity; as it is of the highest im- 
portance that professional confidence should be 
respected and held inviolate. Quoting from an 
English case: "I doubt very much whether a doctor 
called in to assist a woman in procuring an abortion, 
for that in itself is a crime, but for the purpose of 
attending her and giving her medical advice could 
be justified in reporting the facts to the public prose- 
cutor. There might be cases when it is the obvious 
duty of a medical man to speak out and it would be 
a monstrous thing for a medical man to screen a 
person going to him with a wound which it might 
be supposed had been afflicted in the course of a 
deadly struggle." The above is a quotation of 
Lord Brampton's remarks before the Royal Col- 
lege of Physicians of London in 1896. 

In 1 9 14 the English Courts had to deal with a 
case of an alleged illegal operation on a woman on 
whom three successive doctors had been in attend- 
ance. None of these doctors had given information 
to the police, and there was consequently no ev- 
idence upon which to convict the prisoner who was 



charged with having performed the illegal operation. 
The court in discussing the failure of the attending 
physician to report the matter stated: ''No one 
would wish to see disturbed the confidential re- 
lation which exists between the medical man and 
his patient, but there are cases, and it appears to 
me that this is one, where the desire to preserve 
that confidence must be subordinated to the duty 
which is cast upon every good citizen to assist in 
the investigation of a serious crime such as is here 
imputed to this woman. It may be the moral duty 
of the medical man, even in cases where the patient 
is not dying, or not likely to recover, to communicate 
with the authorities when he sees good reason to be- 
lieve that a criminal offence has been committed." 
The trend of the above decision will be noted to be 
somewhat contrary to the one previously cited, and 
holds that medical men are under the same moral 
duty as other citizens in all cases where they become 
aware of the commission of a crime, to report it to the 
authorities. The above two different opinions, 
when brought to the attention of the British Medi- 
cal Association, caused it to appoint a committee to 
confer with the Lord Chief Justice upon this impor- 
tant question. This deputation was received by the 
Lord Chief Justice on May 3, 191 5, and the sum- 
mary of the resolutions passed by the Royal College 
of Physicians of London, as a consequence of said 
interview, is as follows: That a medical practitioner 
is not justified in disclosing information obtained in 
the course of professional attendance upon a woman 
without her consent, but that when he is con- 
vinced that a criminal abortion has been performed 
on his patient he should urge her, especially when 
she is likely to die, to make a statement which may 
be taken as evidence against the person who has 
performed the operation, provided always that her 
chances of recovery are not thereby prejudiced; 
and that in the event of her refusal to make such a 
statement he is under no legal obligation to take fur- 
ther action; that in the event of the patient dying 
he should refuse to give a certificate of the cause of 
death and should communicate with the coroner. 

John A. Castagnino. 



GYNECOLOGY 



UTERUS 

Goodwin, R. T.: Lacerated Cervix. Texas St. J. 
Med., 1916, xi, 542. 

The author reviews the anatomy of the cervix, 
gives the most frequent symptoms of lacerations of 
the cervix, the resvilts produced thereby, and con- 
cludes by discussing the operative treatment. 

Lacerations of the cervix are very common. The 
chief cause of cervical tears is meddlesome obstetrics; 
for example, want of care or judgment in the use of 
forceps, '.remature rupture of the bag of waters, 
the injudicious use of the drugs, ergot and pituitrin, 
mechanical dilatation of the cervix, and roughness in 
performing podalic version. 

The symptoms are not pathognomonic and are 
due to the lesions caused by the laceration. The 
most constant of these secondary conditions are, 
subinvolution of the uterus, endometritis and 
uterine displacements; and the symptoms usually 
described as being due to lacerations of the cervix 
are in reality caused by one or all of these complica- 
tions. Backache, bearing down in the pelvis, 
vertical headache, leucorrhoea, menorrhagia, metror- 
rhagia, sterility and abortion, are the most frequent 
of these symptoms. 

The results of the lacerations are either immediate 
or remote. Of the immediate results the most fre- 
quently observed are haemorrhage, sepsis, and vesico- 
vaginal fistula. The principal remote results are 
subinvolution of the uterus, chronic endometritis, 
uterine displacements, due to subinvolution or to 
contractions of cicatricial tissue in the cellular 
structures behind the uterus; chronic tubal and 
ovarian disease, and cancer. 

As a large number of lacerations require no treat- 
ment whatever, it is important to have a clear and 
definite idea as to what class of cases require opera- 
tive interference. 

The following rules have been formulated for 
this purpose: 

1. Operate upon all lacerations which are com- 
plicated with induration and hypertrophy of the 
cervical tissues, eversion of the intracervical mucous 
membrane, cystic degeneration, and erosion. 

2. Operate upon all lacerations which are re- 
sponsible for subinvolution of the uterus, endometri- 
tis, and uterine displacements. 

3. Operate upon all lacerations which are asso- 
ciated with a sensitive plug of scar tissue in the angle 
of the wound. 

Any grave pelvic disease is a contra-indication 
for operative interference in laceration of the cervix. 
There is always considerable dragging upon the 
uterus during an operation upon the cervix, and 



these manipulations may cause a fatal peritonitis 
by breaking up old adhesions. Ralph H. Kxxhns. 

Percy, J. F. : Tiie Problem of Heat as a Method of 
Treatment in Inoperable Uterine Carcinoma. 

Tr. Am. Gynec. Soc, Washington, 1916, May. 

There are three stages to be recognized in the 
development of cautery treatment of carcinoma of 
the uterus: (i) that in which it is used merely to 
stop haemorrhage and limit offensive discharge. 
(2) in the galvanocautery excision of the cervix 
uteri, developed by the late Dr. John Byrne of 
Brooklyn. (In this technique a degree of heat 
sufficient to cut the tissues was used); (3) in the 
dissemination of a coagulating degree of heat 
through the widest area possible of the cancer 
mass, with no attempt at immediate excision of the 
parts (Percy). 

The technique of Byrne was not designed for 
advanced inoperable cancer in which the uterocer- 
vical junction is fixed, with extensive malignant and 
inflammatory infiltration of both broad ligaments 
and the perimetrium. As classified today, Byrne 
operated only in the first steps of cervical cancer 
involvement. He deplored the use of the cold steel 
knife in cervical cancer and forty-four years ago re- 
ferred to it as "a comparatively fruitless procedure 
at best." This is just as true today — without the 
preliminary use of heat — as it was in his day. The 
cases treated by Byrne with galvanocautery ex- 
cision of the cervix were the type of cases which 
would be considered suitable for the Reis-Wertheim 
treatment of today. 

The author has the following to say as to the 
future of the heat treatment: "The stage of op- 
erability with my present technique is easily 90 
per cent, and I confidently expect that, if the 
promise which I see in my work is realized in the 
further development of the use of heat in cancer, 
the stage of operability will be without limit in 
strictly pelvic cancer. I would not have you be- 
lieve, however, that the ideal is mere operability. 
Back of it all is the hope and promise of results 
never before obtained by any method so far de- 
veloped in that disease which has always stood as a 
synonym for incurableness, pelvic cancer. In 
conclusion permit me to re-emphasize the following 
points: 

I . "The Percy technique, so-called, is not a cautery 
operation. I remove nothing. The tissues, fol- 
lowing the application of moderately low degrees of 
heat, are literally coagulated and slowly dissolve. 
It usually takes two weeks for a healthy granulating 
surface to appear beneath the gradually dissolving 
•mass of inert cancer debris. 



69 



70 



INTERNATIONAL ABSTRACT OF SURGERY 



2. "The operation of Byrne was a high galvano- 
cautery incision of the cervix. There could be but 
little penetration of heat. Byrne recognized this 
when he advised that the surface left after the re- 
moval of the gross mass be seared over with the 
cautery knife in order to get all the heat penetration 
possible. But Byrne never thought of applying 
heat to the degree of obtaining penetration sufficient 
to render movable the fixed tissues in the pelvic 
basin. If the fixed tissues, malignant and inflam- 
matory, are not made freely movable, as they are 
normally, the heat penetration has not been suffi- 
cient, and, therefore, is inefifective. 

3. "To coagulate a large mass of uterine cancer 
requires from thirty to sixty minutes, and if the 
broad ligaments still remain stiff, or fixed, an ad- 
ditional ten minutes. 

4. "In my effort to emphasize the importance of 
avoiding the burning temperatures, I fear that I 
have led many surgeons to the opposite extreme, 
and that they are trying to destroy the activity of 
an inoperable mass of cancer with a temperature so 
low that days, rather than hours, would be required 
to make the heat effective. Byrne fried his tissues. 
I broil, or pasteurize, them. The Byrne technique 
was based on the use of heat as an acute process. 
Mine is not acute, but chronic, both as to time and 
degree. Heat, more heat, and yet more heat; but 
heat, not fire; broiling, not frying; not roasting, but 
curdling; pasteurization, not desiccation; coagula- 
tion, not carbonization. 

"In its practical application, the whole technique 
can be summed up in the one statement: Do not 
carbonize the tissues. For in the degree that this 
is done, in that degree is heat penetration inhibited; 
and heat penetration is the vitally essential thing. 
A gentle simmering sound only should be heard 
when the ear is placed near the vaginal water-cooled 
speculum. This simmering sound is produced by a 
temperature above 45° C. (113 F.). It probably 
ranges from 83 to 93° C. (180 to 200° F.). Heat 
in the cancer, operable or inoperable, or as a pre- 
liminary to the use of the cold steel knife, has, with 
its present development, come to stay. It offers 
more in the way of cure in the early case than any 
other treatment so far devised. In the late case it 
promises surcease from suffering, with a prolonga- 
tion of life that is most hopeful. 

"But more than all else, we have not yet fully 
learned the technique of most effectively destroying 
cancer in the accessible regions of the body by heat. 
When we do, another chapter will have been written 
in the history of man's contest with his physical 
ills that will compare very favorably with anything 
so far accomplished along the lines of scientific 
endeavor." 

Ransohofi, J. and J. L.: Radium Treatment of 
Uterine Fibroids. Lancet-Clin., 1916, cxv, 116. 

The authors believe that radium is the method of 
choice in the treatment of uncomplicated uterine 
fibroids, as the treatment is safe and in the usual' 



case the symptomatic cure almost certain. It 
should not be used where there is a reasonable doubt 
in the diagnosis, or where the fibroid is complicated 
by infections of the tubes and ovaries. 

Operation should also be the method of choice 
where pressure symptoms are so acute as to demand 
immediate relief. 

Radium treatment is superior to X-ray treatment, 
because the radium can be brought into intimate 
contact with the fibroid itself and does not depend 
on its action on the ovaries. 

Four typical cases are cited. One particularly 
interesting case was that of a fibroid in a woman past 
the menopause, occupying the entire pelvis and 
extending two inches above the umbilicus. Under 
radium treatment a complete disappearance of the 
tumor was secured. Operation in this case would 
have been unfavorable, because of the presence of a 
large anuerism of the arch of the aorta. 

Condit, W. H.: Compensatory (Vicarious, Ec- 
topic) Menstruation; Xenomenia; Memmes 
Devii. Am. J. ObsL, N. Y., 1916, Ixxiii, 238. 

The author reports the interesting case of a young 
woman who had a hysterectomy and bilateral sal- 
pingo-oophorectomy, yet each month had the sub- 
jective symptoms and sensations which had char- 
acterized her previous normal menstrual periods 
and had a haemorrhage into some of her cutaneous 
tissues. Fifteen days after the operation at the 
regular menstrual time she had a haemorrhage into 
a naevus the size of a split pea situated over the left 
ninth intercostal space. It attained the size of a 
hen's egg and there occurred a considerable ecchy- 
mosis in the skin about the naevus. In four days 
the tumor diminished in size one-half and soon the 
skin ecchymosis disappeared. No blood escaped 
from the tumor or skin. This process was repeated 
regularly every twenty-eight to thirty-four days 
for twenty-one months until the tumor mass which 
had gradually formed ruptured and she at last con- 
sented to operation. Microscopic sections were 
negative for melanosis. 

At the next regular period the left mammary 
gland was attacked in a similar manner but after 
one year the manifestations in this gland became less 
frequent and regular, and at the end of two years 
it had returned to practically its normal appearance. 
The author now hoped that relief had come, but 
she then had an extensive subctuaneous haemor- 
rhage into the extensor surface of both legs, ac- 
companied by pain and extreme ecchymosis from 
the thighs to the knees; similar attacks occurred 
in one leg thirty-four days later and were repeated 
each month. The last attack occurred in July, 
1914, seven years and three months after the op- 
eration. It involved the posterior surface of her 
right leg from the gluteal fold to the ankle, being 
most marked over the popliteal space. 

The conclusion arrived at in this study is that 
menstrual abnormalities or irregularities are due to 
blood-pressure changes in the individual, together 



GYNECOLOGY 



71 



with some atrophic or pathological changes in part 
or parts where the haemorrhage manifests itself. 
In the particular case reported, the peculiar dem- 
onstrations were brought about by a failure of the 
individual physical economy to adapt or adjust it- 
self to the change brought about in the blood-pres- 
sure by removal of part or parts previously acting 
as the safety valve of this particular economy. 

C. H. Davis. 

Lange, S.: Recent Results in the X-Ray Treat- 
ment of Menorrhagia, Dysmenorrhoea, and 
Uterine Myoma. Am. J. Roentgenol., 1916, ill, 
72. 

Lange's paper is based upon 50 consecutive cases 
of menorrhagia, dysmenorrhoea, and uterine fibroids 
treated by X-ray therapy. In every case a satis- 
factory result was achieved, an artificial menopause, 
apparently permanent, occurring in every case in 
which it was desired, regardless of the age of the 
patient. These cases were referred from many 
different sources, and while only ordinary care and 
skill were employed in their selection, malignancy 
has not developed in any case either during or fol- 
lowing the treatment. So far as he has been able 
to follow the case there has been no recurrence of 
the menstruation after it has once stopped. In 
several cases there has been an occasional faint 
menstruation during the few months just following 
the menopause. After a lapse of a few months, 
however, abatement of the ovarian function has 
been complete and permanent. He has found it to 
be a safe working rule that if one period is missed all 
treatment may be discontinued. 

In this series of 50 cases, 19 were treated because 
of persistent menorrhagia. The ages of the patients 
varied from seventeen to fifty years. The minimum 
of X-radiation required to bring about a permanent 
menopause was one treatment (100 X) in a woman of 
forty-nine. The greatest amount given any patient 
was 800 X (eight treatments) which was required 
to abolish the ovarian function in a girl of twenty. 
Another patient of seventeen years of age required 
only 700 X to accomplish the same result. A 
woman of twenty-eight required 600 X (six treat- 
ments). A woman of thirty-two required 500 X. 
With increase in the age of the patients the amount 
of X-radiation required rapidly decreases. 

The equipment consists of a Coolidge tube 
backing up a spark gap of nine to nine and one-half 
inches, and a 6ter consisting of 3 mm. of aluminum 
and a thick layer of sole leather. With a target 
skin distance of six inches 10 milliamperes are passed 
for 2.5 minutes (over 20X through each of four areas, 
or about 100 X for each treatment). 

Within a month Lange would give three such 
treatments, but in a footnote concedes the possibility 
of an error in his Kienbock readings and that other 
operators would use an interval of three weeks be- 
tween treatments. (A caution the unskilled op- 
erator would do well to consider carefully.) 

David R. Bowen. 



Collins, A. S. A. W. : An Operation for Retrodis- 
placement of the Uterus. Am. J. Surg., 1916, 
XXX, 92. 

The uterus is held in normal position; the round 
ligaments are caught with Kelly forceps and brought 
toward the median line; and about i inch of the perito- 
neum is peeled back from close to the tip of the 
forceps. 

As the object of the operation is to maintain the 
uterus sufficiently anterior so that intra-abdominal 
pressure is exerted upon the posterior surface of the 
fundus, and also to overcome a prolapse of the 
ovaries, one of two methods must be decided upon. 
Either bring the ligament under the round and 
ovarian ligaments through an opening in the broad 
ligament posteriorly, as in Webster's operation, or 
anteriorly. 

A stab with a knife is made under the peritoneum 
and about a sixteenth of an inch into the muscle of 
the uterus and brought out again. The knife should 
be narrow and the wound made just large enough to 
accommodate the round ligament. The same is 
done on the opposite side and the ligaments are 
then sutured in place. The operation is rapidly 
done. There are no raw surfaces and no bleeding. 

1. It is a muscle-to-muscle attachment and no 
possibility of a pulling away to one side or another. 

2. It is not a peritoneal attachment which forms 
an adhesion and will stretch or give way altogether. 

3. There is no interference in pregnancy. (The 
author has had four patients who have gone through 
labor normally with the uterus in good position 
afterwards.) 

4. No bladder or other subjective symptoms 
follow. 

5. The uterus remains mobile. 

Edward L. Cornell. 

Handfleld- Jones, M. : Clinical Aspect of the Double 
Uterus in Its Relation to Diagnosis and Treat- 
ment. Lancet, Lond., 1916, cxc, 574. 

The paper is based on the reports of 10 cases of 
this condition, 8 of which came under the author's 
observation. The cases were selected to illustrate 
certain clinical points. Among them were: (i) a 
case in which septic infection of the second unim- 
pregnated uterus occurred after delivery of a child 
from the other uterus; (2) a case in which twin 
foetal sacs were removed from one uterus and the 
patient safely carried to term a single pregnancy in 
the second uterus; (3) a case of haematometra in a 
double uterus; (4) a case illustrating obstruction 
to delivery by the unimpregnated portion of a 
double uterus; (5) a case in which the unimpregnated 
uterus was safely drawn up out of the way of the 
pregnant portion, and delivery was unobstructed; 
(6) a case in which death occurred from sepsis and 
haemorrhage following an attempt to divide the 
septum separating the two uteii, both of which 
were pregnant, after the first uterus had been safely 
emptied; (7) a case in which pregnancy proceeded 
to full term in one half of a double uterus after 



72 



INTERNATIONAL ABSTRACT OF SURGERY 



the other uterus had been emptied by curettage in 
the early months; (8) a case in which a double 
vagina was discovered by the patient herself; and 
(9) a case in which pregnancy proceeded safely to 
term after the condition had been demonstrated 
by an exploratory laparotomy in the early months 
of pregnancy. C. D. Hauch. 

Gallant, A. E.: The Removal of the Troublesome 
Useless Uterus. N. ¥. M. J., 1916, ciii, 485. 

Eliminating hysterectomies for (i) life-destroy- 
ing disease and (2) for conditions detrimental to 
health or dangerous to life, the author goes on to 
the consideration of (3) removal of the uterus be- 
cause of conditions the source and cause of health- 
destroying discomfort; "troublesome" because they 
were the cause of intractable suffering; "useless" 
because they were either absolutely, relatively, or 
practically incapable of performing the one sole 
function of the uterus — reproduction. In 12 women, 
between 57 and 73 years, who had ceased to men- 
struate; the senile uteri were removed because of a 
prolapsed bladder with or without rectocele or 
descent of the uterus or intestines, in 7 cases; 
uterosacral ligament retrofixation, 4 cases; chronic 
pyometria and ovarian sarcoma (?), one case. 
The second group included 11 women, whose ages 
ranged from 37 to 47 years, and who were still 
menstruating. Four had passed the "approximate" 
age for the menopause, from 2 to 11 years; while 
the other 7 still had in prospect from one to five 
years longer to flow, normally. The average range 
of fertility was from one to seven children; the most 
recent birth seven months previous to operation; 
the average length of sterility was between six and 
seven years. 

The third group included 7 suffering women 
between 30 and 34 years, in the full tide of repro- 
ductive activity, who had not been benefited by 
local and general treatment or by conservative 
operations. 

Gallant, when deciding to operate or not to 
operate, was influenced, largely, by (i) the severity 
of the symptoms; (2) the effect on the general 
health; and (3) the environment. Excessive ner- 
vousness was the one predominating complaint 
in all but one instance. Dysmenorrhoea came next 
in order of frequency, usually of a severe type, 
lasting throughout the flow, and compelling the 
sufferer to lie down for a few hours or go to bed for 
one, two, or even three days of each period. Back- 
ache was a very common symptom, located by 
placing the hands over the sacral region, variously 
described as "come and go pain," dragging, tearing, 
bearing down, falling, and present all the time, 
during the monthlies, not so bad between, etc., 
but to each one very trying and very real. Head- 
ache, suboccipital, was present in over half the 
cases, and of a truly torturing variety, relieved 
only by some sort of "dope." Ilio-abdominal 
pain, when not of appendicular origin, was of a 
dragging, tearing, burning character, and referable 



to tension on the round ligaments, or enlargement 
or adhesions of the tubes and ovaries, distinguish- 
able from the appendix only by actual palpation. 
Dyspareunia was present whenever the vagina was 
raw or the uterosacral ligaments immobilized the 
uterus. 

Dysuria, with frequent, painful urination, was 
nearly always associated with a demonstrable 
trigonitis, an acid vaginitis, and acid urine of high 
specific gravity. 

The conditions calling for operation were pro- 
lapsed bladder, with or without prolapse of the 
uterus and rectum, 11 cases; retroversion, 17 cases; 
uterine fixation, 16 cases; hypertrophied uterus, 
15 cases; anteflexion, 4 cases; lacerated cervix, 
6 cases; perineum, 11 cases; diseased ovaries and 
tubes, 6 cases; persistent vaginitis, 6 cases; with 
goiter, 3 cases; visceroptosia, 12 cases. 

The operative measures employed were vaginal 
hysterectomy, 19 times, with salpingo-oophorec- 
tomy, I case ; complete excision of vagina, 3 cases ; 
partial excision, 4 cases; supravaginal, 4 cases; with 
ovaries and tubes, i case; abdominovaginal pain, 
2 cases; abdominal pain, 2 cases; anterior colpor- 
rhaphy, 2 times; perineorrhaphy, 6 times; appen- 
decectomy, 4 times; uterine drainage, 2 times; 
drainage through the cervical stump, 2 times; con- 
servative (?) amputation of cervix, 2 times; resec- 
tion of sigmoid, i case. This last patient died on the 
fifth day after operation, presumably from rupture 
at the site of the resection brought about by her 
strenuous efforts to avoid soiling the bed. One other 
died, 28 days after complete closure of the vagina, 
from "hypostatic pneumonia." 

In conclusion. Gallant states his belief that re- 
moval of a troublesome, useless uterus is not only 
justifiable but the most rational procedure in the 
following conditions: 

1. In senile women, complete denudation and 
closure of the vaginal canal is the one sure and 
permanent means of curing hernia vaginae. 

2. In well-nourished women, who have ceased 
to menstruate, or who have passed or are approach- 
ing the "approximate age" when the menses 
should cease, hysterectomy and partial colpectomy 
will prove beneficial and still provide for marital 
relations. 

3. In menstruating women under thirty-five 
years, after every means to conserve childbearing 
function have been exhausted; when the conditions 
cause a life of semi-invalidism; when they prevent 
her from working and earning a livelihood; when 
they seriously interfere with her duties to her hus- 
band and children and condemn her to a life of 
unalloyed suffering, then and then only, as a last 
resort, should the uterus be removed. 

4. Whenever the pelvic conditions are associated 
with a troublesome, colicky appendix, or simple or 
exophthalmic goiter they should be removed. 

5. Whenever combined with visceroptosis a cure 
cannot be expected unless the patient is fitted with 
an appropriate corset. 



GYNECOLOGY 



73 




Fig. I. 

Fig. I. Section from the interior of a bony nodule 
withm the ovary, showing bone lamellae, haversian canals, 
and bone-marrow. (Moschcowitz.) 

Fig. 2. Low-power section taken near the periphery of 
the bony nodule. Space within the lime-containing 

ADNEXAL AND PERIUTERINE CONDITIONS 

Moschcowitz, E. : The Relation of Angiogenesis 
to Ossification, Based upon the Study of 
Five Cases of Calcification and Ossification 
of the Ovary. Bull. Johns Hopkins Hosp., 1916, 
xxvii, 71. 

Within a comparatively short time the author 
has been able to study in the pathological laboratory 
of the Beth Israel Hospital three cases of calcifica- 
tion and two of ossification of the ovary. The lesions 
were studied particularly from a morphological 
viewpoint. The process in each instance involved 
a corpus albicans. The specimens represented an 
apparently continuous series, in which four stages 
were recognizable: (i) an early discrete multiple 
deposit within a healed corpus luteum; (2) a defin- 
itely circumscribed deposit of amorphous lime 
within a corpus albicans; (3) the formation of pri- 
mary haversian canals, which is accomplished by 
the genesis of an active mesoblastic tissue, both 
upon the surface and within the interior of such a 
circumscribed lime deposit (This mesoblastic tissue 
is derived from the adjacent blood-vessels of the 
ovary, and the predominant activity is the develop- 
ment of new blood-vessels; associated with this 



Fig. 2. 
area filled with delicate fibrous tissue, fibroblasts, and young 
blood-vessels. Along the circumference of these spaces 
are fibroblasts which have penetrated into the surround- 
ing lime-containing tissue, revealing a coincident lime 
absorption. (Moschcowitz.) 

activity is the development of osteoblasts from the 
mesenchymal cells.); (4) true bone formation, 
with maturation of all the elements described above, 
together with eccentric deposition of bone-plates 
around the primary haversian canals and the forma- 
tion of marrow. 

Moschcowitz states that the development of new 
blood-vessels affords the keynote to the interpreta- 
tion, in terms of cellular ontogeny, of the process of 
ossification, and that the histological constituents 
which enter into the formation of new blood-vessels 
are the progenitors of all the histological components 
of osseous tissue. In other words, that blood-vessels, 
osteoblasts, bone-cells, and marrow (in part at least) 
are merely differentiations of the mesenchymal cell 
unit. 

To his mind, the author's specimens furnish strong 
corroboration of the "adaptive," or "mesenchymal" 
theory of angiogenesis, and to the theory of the 
non-specificity of endothelium. Ossification, he 
believes, does not occur without preliminary calcifi- 
cation, and calcification occurs only in dead tissues, 
and there is no valid reason for regarding bony 
structures within the ovary as biastomata. 

George E. Beilby. 



74 



INTERNATIONAL ABSTRACT OF SURGERY 



O'Shansky, A. L.: Infection of Ovarian Dermoid 
Cyst with Typhoid Bacillus. /. Am. M. Ass., 
1916, Ixvi, 888. 

Two months after an attack of typhoid fever, 
a school-teacher, aged 21, noticed a mass in the 
abdomen. One month later she was operated 
upon. A large ovarian cyst on the left side was 
aspirated and about two quarts of thin pus removed. 
A few strands of hair were attached to the cannula 
on removal. The tumor was ligated at its pedicle 
and removed. 

On bacteriologic examination, a smear showed a 
gram-negative bacillus. The growth showed a 
gram-negative motile bacillus in pure culture 
which did not produce gas in sugar mediums, did 
not liquefy gelatin, and did not coagulate milk. 

Pathologic examination of the cyst in gross after 
fixation revealed a growth 15 by 15 by 11 cm. in 
its largest diameters. The fallopian tube was 
attached on one side. When the cyst was opened, 
a quantity of grayish liquid, containing a fatlike 
substance, such as is commonly found in dermoid 
cysts, came out and masses of this fatty material 
containing hairs were removed. At one portion, 
where the wall was thickest, there was a tuft of 
hair growing from the wall. At another portion 
there was a short nipple-like projection somewhat 
calcified. Microscopic examination revealed an 
infected ovarian cyst. 

The patient made an uneventful recovery and 
has had no further complications. 

Edward L. Cornell. 

Abelio, G. : Strangulated Fallopian Tube, Ovary, 
and Intestine in an Infant. /. Am. M. Ass., 
1916, Ixvi, 813. 

The patient was a girl, aged 11 months, breast- 
fed, and with no febrile or diarrhoeal disturbances of 
any sort. Three months previous to operation she 
■developed a mass in the right inguinal region, the 
appearance of which was associated with apparently 
severe abdominal pain and vomiting. Prior to 
this no such mass had been noticed by the parents. 
Taxis was successful in three attacks. Two months 
later a mass appeared in the right inguinal region; 
the baby began to cry as if in severe pain; vomiting 
set in. Unsuccessful attempts at reduction had 
already been made. She had had no bowel move- 
ment for about 48 hours. Examination revealed a 
somewhat distended abdomen, not by any means 
tense, and a right inguinal mass, about 5 cm. in 
diameter and elevated above the normal skin level 
to the extent of about 2 cm. This mass was ex- 
quisitely tender and very tense. Immediate op- 
eration was advised and performed. 

An oblique incision above the mass displayed a 
well-formed, spherical, tense, dark-colored peritoneal 
sac bulging directly forward through the external 
ring. The contents consisted of a large almond- 
sized mass, readily recognized as the ovary, to the 
postero-external aspect of which was attached a 
tiny fallopian tube. Posterior to both was a knuckle 



of dark-colored small intestine. Very slight trac- 
tion on the intestine was made, a Kocher director 
inserted between it and the neck of the sac and the 
latter nicked enough to enable reduction to be made 
of the herniated viscera. Several minutes after the 
release of the constricting neck, the ovary had 
reduced about 100 per cent in size and the intestine 
became a very deep red. The opening in the perito- 
neum was closed, muscle and fascia approximated 
to Poupart's ligament and the lower leaf of the 
external oblique imbricated over this line of sutures. 
The skin was closed with silkworm gut and the whole 
covered with a gutta-percha collodion dressing. 
Three hours after the operation a copious, very foul 
smelling bowel movement resulted. The conva- 
lescence was uneventful. Edward L. Cornell. 

Moore, J. E.: Salpingitis Secondary to Appen- 
dicitis. Surg.,Gynec. b" Ohst., 19 16, xxii, 277. 

The small entrance into the tubes from the 
uterine side would seem to be one of nature's 
provisions to prevent bacteria from entering the 
peritoneal cavity through the natural channels. 
The fimbriated extremity of the tube is wide open, 
and if any bacteria are present in the peritoneal 
side they can easily gain entrance to the tube. 
Under normal conditions the tubes are further 
protected on the uterine side by a sterUe uterus and 
only become infected under abnormal conditions 
of the uterus. 

It is rational to conclude that when abnormal 
conditions obtain within the peritoneum the tubes 
may be infected from the peritoneal end. It is well 
established that the majority of cases of salpingitis 
are due to a gonococcus infection, but there are 
many due to other bacteria. Cases are cited to 
prove that appendicitis is not an uncommon cause 
of salpingitis. The author believes that it should 
be accepted as an established fact that a certain 
small percentage of cases of salpingitis are due to 
appendicitis, so that when looking for possible 
causes of the pelvic inflammation this fact may be 
taken into consideration. 

EXTERNAL GENITALIA 

Gellhom, G., and Ehrenfest, H.: Syphilis of the 
Internal Genital Organs in the Female. Tr. 

Am.Gynec. Soc, Washington, 1916, May. 

At present it is impossible to estimate even ap- 
proximately the full extent to which syphilis exists 
in the world. The latest statistics which tend to 
show that 10 per cent of the male population of the 
United States are affected are probably far too con- 
servative. 

Syphilis has always been assumed to be consider- 
ably commoner among men than among women, 
but from certain investigations this supposition 
cannot yet be accepted as conclusive. At any rate 
syphilis is common enough in women to constitute a 
gynecologic problem in the widest sense. Not every 
disease in a syphilitic woman is syphilitic in nature, 



GYNECOLOGY 



75 



but syphilis if present will exert an influence of its 
own upon coexistent diseases. Moreover, latent 
syphUis prevails more in women than in men. 

The course of syphilis in men differs in many 
points from that in women. To cite but one of the 
differences, the relative frequency of tabes and 
paresis in the two sexes is well known. 

Syphilis of the internal genitals in women pre- 
sents a number of problems as yet unsolved. The 
question of infection by the sperma of a syphilitic 
man is discussed; also the possibility of differences 
in the strains of spirochaetae which might have a 
predilection for one part or the other of the female 
genital tract. There is, finally, the question whether 
certain parts of the genitaUa possess a sort of relative 
immunity. 

Primary chancres of the vagina are rare, probably 
because of certain histologic and biologic character- 
istics of the vagina. The typical signs of sclerosis of a 
mucous membrane; i.e., parchment-like induration, 
persist as a rule only for a short time. Under 
ordinary circumstances, spontaneous restitution 
occurs after about two weeks. The absence of 
definite symptoms, such as pain or vaginal discharge, 
and the insignificance of any remaining scars 
probably result in many cases in failure or even 
inability to correctly diagnose this lesion. 

Secondary syphilitic lesions of the vagina are 
very rare. They occur either in the form of macules 
or papules; the latter variety seems to be relatively 
more frequent. They have no symptomatology 
of their own, and therefore are discovered only 
accidentally during an examination with the 
speculum. 

Tertiary luetic manifestations of the vagina are 
also extremely rare. They represent as a rule the 
continuation of secondary lesions in the vulva, 
uterus, or adjoining organs. The isolated sub- 
mucous gumma breaks down early and appears in 
the form of a more or less characteristic ulcer. The 
more destructive processes which eventually lead 
to the formation of fistulse and strictures, almost 
always originate in structures surrounding the 
vagina. Tertiary lesions of the vagina- do not 
exhibit characteristic symptoms such as pain or 
discharge. 

Primary chancre of the cervix represents the 
best known and most common type of syphilitic 
affections of the female internal genitalia. Its 
frequency has probably been overestimated. 
Statistics based on a large number of observations 
have never shown a frequency of over 1.5 per cent of 
all primary chancres found on the genitalia. It 
must, however, be admitted that in a considerable 
number of cases its presence on the vaginal portion 
of the cervix is overlooked. 

Primary chancre of the cervix does not give 
rise to any noteworthy clinical symptoms. There- 
fore, as a rule a search for it is made only after the 
appearance of the secondary exanthema. Under 
normal conditions the primary lesion heals with such 
rapidity that its existence in a large percentage of 



cases can only be surmised from certain findings 
which in themselves are not characteristic. 

Not even during its existence does the primary 
chancre offer a truly characteristic and pathognostic 
aspect on account of its rapid and variegated evolu- 
tion from an uneroded induration to an ulcer which 
in turn either heals quickly or transforms into an 
inconspicuous erosion. 

Considering the absence of palpable satellite 
buboes and the difficulty of ascertaining the char- 
acteristic induration of its base, a suspicious looking 
sore on the cervix can be identified as primary hard 
chancre only if the spirochaeta pallida can be re- 
covered from its surface and if the cervical lesion 
is followed by a typical secondary exanthema. 

Eight personal observations have been added by 
the authors to the few cases found in the literature 
of secondary lesions of the cervix. Syphilis mani- 
fests itself upon the cervix in the form of macules, 
papules, and ulcerations. These forms probably 
represent three successive stages in the develop- 
ment 'of a lesion caused by scattered accumulations 
of the spirochaeta pallida in the squamous mucosa 
of the cervix. The parasite can readily be re- 
covered from the secretion of any of the three forms, 
and this explains the great infectiousness of sec- 
ondary lesions. Wassermann is positive in this 
stage. Macules and papules have no sympto- 
matology of their own while iilcers may give rise to a 
profuse yellowish discharge. Occasionally, a pe- 
culiar puffiness of the fornices may be present. The 
leucoplastic appearance of macules, the char- 
acteristic form of the papules, and the typical 
yellowish color of the ulcerations render diagnosis 
comparatively easy. Secondaries in other parts of 
the body form a valuable aid. Cervical lesions as a 
rule heal quickly and may disappear without leaving 
any traces. Specific treatment, energetically ap- 
plied, brings about resolution in a very short time. 

Actual knowledge concerning syphilitic lesions 
of the uterine body is extremely meager. Primary 
and secondary manifestations have not yet been 
observed in the uterus. A few instances of gumma 
in the uterine waU have been recorded. An isolated 
observation by Hoffmann proves the possibility of 
gummatous changes in the endometrium. This 
infrequency of tertiary lesions is a matter of sur- 
prise, for the uterus more than any other internal 
organ of the body is exposed to direct infection. 
Spirochaetae may reach the uterine cavity from the 
vagina or lesions of the cervix. It is certain that 
an actively syphilitic mother invariably infects the 
fcetus. In every pregnant syphilitic woman spiro- 
chaetae must be present in the endometrium. Un- 
less syphilitic lesions of the uterus have been over- 
looked in the past, we are forced to assume a 
relative immunity on the part of the uterus. 

It seems possible that the tubes may be the seat 
of luetic lesions, but the pathological and clinical 
material on record is yet too incomplete to permit 
of positive assertions. Spirochaetae have never 
been found in the tubes of syphilitic women. 



76 



INTERNATIONAL ABSTRACT OF SURGERY 



Various changes in the ovaries (simple enlarge- 
ment, syphilitic oophoritis, tertiary sclerosis of the 
ovary, ovarian gumma) have been described as 
tjrpical expressions of the secondary and tertiary 
stages of luetic infections, but in no instance, with 
the possible exception of Hoffmann's case, has posi- 
tive proof been furnished that such alterations are 
actually due to a local leutic process. 

The fact that in some syphilitic patients either 
an amenorrhoea or, more commonly, a metrorrhagia, 
disappears after specific medication cannot be ac- 
cepted as evidence of a syphilitic ovarian lesion. 
Spirochsetae have as yet not been demonstrated 
in the ovaries of adults. 

Syphilis of the pelvic cellular tissue appears in 
the form of a diffuse gummatous infiltration which 
secondarily involves the pelvic peritoneum. To the 
few cases on record the authors have addecj a 
personal observation. In almost all instances a 
wrong diagnosis of malignancy has been made. In 
their own case the positive outcome of the Wasser- 
mann reaction together with other unmistakable 
signs of tertiary syphilis about the outer genitals 
aided in arriving at the correct diagnosis. Specific 
treatment produces amazingly quick improvement 
of an apparently hopeless condition. 

Syphilis may be the causative factor of disturbed 
menstrual function for various reasons. Impair- 
ment of general health and disorder in the harmo- 
nious synergism of all endocrine glands through the 
affection of one may in the course of a luetic in- 
fection interfere with normal ovarian activity. 
Therefore, in syphilitic patients specific medication 
may correct a menorrhagia or metrorrhagia which 
has proved refractory to the customary modes of 
treatment. Such prompt therapeutic effect, how- 
ever, does not permit of a diagnosis of luetic pro- 
cesses in the uterus or in the ovaries, because uterine 
lesions probably never, and syphilitic ovarian le- 
sions, if actually existing, are but rarely responsible 
for abnormal uterine haemorrhages. 

The Wassermann reaction is found positive in a 
very large percentage of patients suffering from 
metrorrhagias. This is not surprising. Luetic 
women through the common complication with 
gonorrhoea and as the result of frequent abortions 
are particularly prone to develop gynecologic anom- 
alies in which irregular uterine haemorrhages 
represent a predominant symptom. 

The authors recommend a trial with specific 
therapy before radical treatment is decided upon for 
all cases in which a uterine haemorrhage is not defi- 
nitely explained by local findings. 

Normal cervical secretions may contain spiro- 
chaetae during the secondary stage even though there 
are no specific lesions about the genitalia. This 
has been definitely proved by the authors by actual 
observation. The search for spirochaetae may be- 
come as important a part of our diagnostic technique 
as is the stain for gonococci. The prognosis as to 
the danger from infection as well as the time of 
cure may depend upon such an examination. 



As regards the uterus, and more particularly the 
cervix, convincing proofs of the interrelations of 
syphilis and cancer are meager, and it is necessary 
for the present at least, to rely chiefly on the analogy 
with other regions of the body. The following four 
possibilities suggest themselves: 

1. An alteration of all tissues of the body caused 
directly or indirectly by the syphilitic virus — 
Gewebsumstimmung of Neisser — whereby the de- 
fensive apparatus of the organism is weakened. 

2. Any part of the body which in the past has 
been the seat of a syphilitic lesion becomes a 
locus minoris resistentice, wherein a cancer may de- 
velop. 

3. Leucoplacia may represent the connecting 
link between syphilis and cancer. 

4. The direct transition of syphilitic into car- 
cinomatous tissue. 

Microscopic sections are introduced to illustrate 
the probable mode of such transformation. Unless 
arrested in time by antiluetic treatment, atypical 
cell proliferation, such as is stimulated by the 
syphilitic lesion, may lead to carcinoma. 

While actual and well-established facts regarding 
syphilis of the female genital organs are compara- 
tively few in number in contradistinction to the 
many theories and the volume of literature on this 
subject, yet enough is known to compell and hold 
the interest of the gynecologist. 

Syphilis may cause organic lesions in all parts of 
the genital tract such as ulcerations and tumefac- 
tions. The gynecologist will be able to properly 
interpret and treat such lesions only if he is familiar 
with the local pathology of syphilis. He may also 
meet with functional disturbances within the 
genital sphere not explainable by any local findings, 
which may be due directly or indirectly to the in- 
fluence of syphilis. 

There are close analogies between the genital 
organs in the male and the female from a purely 
developmental and anatomical point of view. The 
fact that the ovaries correspond to the testicles, the 
tube to the epididymis, the uterus to the prostate, 
has seemed to many writers sufficient to base de- 
ductions as to the pathology of syphilitic lesions 
in the female upon their knowledge of luetic lesions 
in the male. Such reasoning is faulty. Syphilis in 
many respects affects woman in a manner essentially 
different from man. After all, there is nothing in 
man to compare with disturbances of menstrual 
function which so often confront the gynecologist. 

Gynecology has in the past profited by the pioneer 
work of dermatology in the realm of syphilis. It 
is now time that the gynecologist should contribute 
his full share. There are still many mooted ques- 
tions, such as syphilis without primary lesion or the 
pathology of local lesions in the female genital tract, 
which the gynecologist is amply fitted to solve. 

He should also fall in line with the representatives 
of other specialties in advancing the problem of the 
relationship between cancer and previous syphilitic 
lesions in the same locality. 



GYNECOLOGY 



77 



Familiarity with syphilitic lesions in the genital 
tract must needs prove of. eminent practical value 
to the gynecologist in view of the frequent confusion 
in the diagnosis of cancer and syphilitic ulcerations 
or gummata. That occasionally a patient is sub- 
jected to a serious radical operation who could have 
been cured by antiluetic treatment there can be no 
doubt. 

A more intimate interest in the problems of 
syphilis of the internal female genitalia will advance 
gynecology both in its theory and in its practice. 

MISCELLANEOUS 

Coffey, R. C: Surgical Treatment of Gonorrhoeal 
Tube Infection with a Quarantine Pack. 

Surg.,Gynec. &" ObsL, 1916, xxii, 228. 

The author emphasizes the importance of dif- 
ferentiating gonorrhoeal from pyogenic tube in- 
fection, for in the former case the tube once sealed 
rarely functionates, while in the latter pyogenic 
infection most tubes may be restored to function 
by proper drainage. The pack is made by laying 
wicks all the way across the pelvis in a complete 
wall, the wicks extending to the bottom of the pelvis 
and protruding through the abdominal wound. 
Above this pack of gauze wicks four thicknesses of 
gutta-percha tissue in the form of a large sheet is 
used to protect the intestine from contact with the 
gauze. 

During the past eight years more than fifty cases 
of gonorrhoeal tube infection have been operated 
upon in the very acute stage, with no mortality. 
In four of these the operation was performed so 
early that the tube had not sealed, but a con- 
siderable quantity of pus could be squeezed out of 
the tube. The quarantine pack was placed, attack 
cut short, and in no instance has the patient had 
trouble since. In two other cases where the tubes 
were firmly sealed the tubes were ligated and a 
stump left. In both instances it was necessary to 
do a second operation to remove the stumps. In 
aU other cases excision of the uterine end was prac- 
ticed, followed by the placing of the quarantine 
pack. In all cases the attack was cut short at 



once, and in none of this group of cases has a second 
operation been necessary. 

The author's conclusions are: (i) Acute, violent 
tube infections are best treated by early abdominal 
section. (2) If the tubes have not firmly sealed, the 
pelvis should be quarantined with a pack and the 
tubes allowed to remain unharmed. (3) If the 
tubes are firmly sealed, they should be excised and 
the uterus and ovaries isolated from the intestines 
by a quarantine pack. 

The author believes that many more tubes and 
ovaries will be saved by this method than by the so- 
caUed "conservative" method, and that the usual 
sequelae following gonorrhoeal tube infections will 
be markedly decreased. 

Leeuwen, G. A. Van: Some Remarks Regarding 
Useless, Therefore Undesirable, Operations 

(Quelques remarques k propos des op6rations inutiles, 
done indesirables). Arch. mens, d'obst. et de gynSc., 
1916, iv, 433. 

Many hysterical women in whom the genital 
apparatus is absolutely normal, consult gynecolo- 
gists for pains in the lower abdomen, which they 
refer to the uterus or adnexa. In many such the 
indicated diagnosis is — no genital anomaly: hysteria. 

In examining such women who have come to his 
gynecological cUnic in Amsterdam, Van Leeuwen 
found in a great number a cicatrix of a former 
appendicectomy. He found that the result of such 
operation was favorable in 40 per cent of cases but 
unfavorable in 60 per cent. The unfavorable re- 
sults were generally in cases of chronic appendicitis. 

Diagnosis of chronic appendicitis is difficult, 
especially in women, yet it is often made without 
sufficient reason. It is confounded very often with 
hysterical pains and anomalies. The operation 
which is done on these hysterical subjects is natural- 
ly-insufficient. It is even harmful, because since 
operation has failed to relieve them of imaginary 
pain they will now believe that there is something 
abnormal in their lower abdomen. 

Such operations based on wrong diagnosis are 
not only damaging to the patient, but to medical 
science. W. A. Brennan. 



OBSTETRICS 



PREGNANCY AND ITS COMPLICATIONS 

Van Slyke, L., and Vinograd-Villchur: A Quantita- 
tive Test of the Abderhalden Reaction. Am. 

J. Obst., N. Y., 1916, Ixxiii, 290. 

Owing to the great uncertainty which has been 
associated with the Abderhalden reaction, the au- 
thors have worked in the hope of providing a quanti- 
tative method sufficiently accurate, simple, and 
specific for proteolysis to make the results definite 
and free from subjective influence. They con- 
fined themselves to a study of pregnant with normal 
serum. They utilized placenta prepared in three 
different ways. 

As a standard method for measurement of serum 
protease the aminonitrogen determination seemed 
to them particularly promising for the following 
reasons: First, it is quantitative and permits of 
accurate results with a small amount of material. 
Second, it is specific for proteolysis. The change of 
the non-aminonitrogen of proteins into aminonitro- 
gen is characteristic of protein digestion, and the 
extent of this change affords a direct and quantita- 
tive measure of the extent to which proteid digestion 
occurs. The method, since its publication in 1910, 
has been used successfully in studies of protein 
digestion by various investigators. 

As nearly as possible the same amount of placental 
tissue was used in every case. The utmost care 
was taken to avoid bacterial contamination, and 
the technique was controlled by means of repeated 
cultures with negative results. The chemical 
manipulations were simple, clear-cut, and quantita- 
tive. Duplicate controls always gave closely 
agreeing results. 

Practically every serum, whether from a pregnant 
or non-pregnant individual, showed some definitely 
measurable degree of digestion when incubated with 
placental tissue. The range of individual variation 
in proteolytic activity was wide. The results with 
normal sera cover in each case a range which includes 
most of the results from pregnant sera. After a 
year's, work using the utmost care, the authors found 
that the individual variations of both pregnant 
and non-pregnant sera make the results from both 
overlap so completely as to render the utilization 
of the reaction, even with a quantitative technique, 
absolutely impracticable for either a positive or 
negative diagnosis, even of pregnancy. 

C. H. Davis. 

Evans, D. J.: Eclampsia. Canad. M. Ass. J., 1916, 
vi, no. 

The author is of the opinion that true eclampsia 
is, on the whole, a rather rare complication of preg- 
nancy, and that a preponderant proportion of cases 



diagnosed as eclampsia are really cases of renal 
insufficiency or nephritis; in other words, that in 
the larger proportion of cases the toxaemia is due 
primarily to defective kidneys, while in the remain- 
der, the hepatic type, the renal involvement is 
purely secondary. That it is possible to make a 
diagnosis of true eclampsia during life is thus open 
to question. 

As a general rule, toxaemia occurring late in preg- 
nancy is attended with a marked increase in the 
general blood-pressure. In all cases of pregnancy 
presenting signs or symptoms of toxaemia, the blood- 
pressure should be systematically observed. A ris- 
ing blood-pressure, associated with toxic symptoms, 
headache, constipation, oedema, epigastric pain, 
disturbed vision, albuminuria, etc., are indicative 
of danger, and a pressure of 150 mm. may be con- 
sidered as the danger limit. 

As regards treatment, every individual case must 
be studied and no single method of treatment is 
applicable to all. 

In the presence of evident symptoms of toxaemia 
in the later months of pregnancy, associated with 
albuminuria and casts, and an increased blood- 
pressure, eliminative and sedative treatment is 
indicated. One must rely on milk diet, hot baths, 
the copious use of fluids and purgatives, together 
with rest in bed, to bring about 'mprovement. 
If there be no improvement, indicated by the sub- 
sidence of the albuminuria, reduction of blood-pres- 
sure and disappearance of the general symptoms of 
toxaemia, then labor should be induced. Venesec- 
tion, sweating, the employment of morphia and 
chloral in moderate doses, with purgation and the 
free use of fluids, constitute the treatment of a case 
of actual convulsions. In cases at or near term, 
active surgical methods of delivery may be under- 
taken, but only to save the life of the child, as such 
operations, unless attended with considerable haem- 
orrhage, seem to have but little influence in relieving 
the condition of the mother. Edward L. Cornell. 

Diehl, H. E.: Eclampsia; Studies Concerning Its 
Causes, Nature, and Treatment. N. Eng. M. 
Gaz., 1916, 11, 72. 

As a general average eclampsia occurs in 0.3 to 0.6 
per cent of all cases of confinement: 20 per cent 
coming ante-partum, 60 per cent during labor, and 
20 per cent puerperal. The general predisposing 
causes seem to be primiparity, heredity, contracted 
pelvis, multiple pregnancy, previous renal or hepatic 
disease, and an unstable nervous equilibrium. 
Properly speaking, eclampsia is but one, and the 
most severe as well, of the toxaemias of pregnancy. 

The author reviews the various theories as to the 



78 



OBSTETRICS 



79 



cause of eclampsia and concludes that all cases 
probably do not have the same origin. 

At present and until the cause be specifically 
known, the treatment is indefinite and a matter of 
routine. 

First, however, there are the preventive measures. 
Symptoms suggestive of impending eclampsia are 
headache, nausea, vomiting, seeing spots before the 
eyes, with dimmed vision, epigastric pains, insomnia, 
or an abnormal desire to sleep, twitchings, oedema, 
high blood-pressure, and albuminuria. When such 
symptoms are present dietary measures should be 
taken — especially avoiding proteins and foods 
rich in cellulose; also attention most be given to the 
eliminative channels. If these do not suffice, 
premature induction of labor is decidedly called for. 

After convulsions have occurred there are two 
methods of treatment: (i) to deliver the patient at 
once; (2) delivery in no case but attempting to con- 
trol convulsions by the administration of morphia or 
chloral or both and venesection. 

Remove toxic material by any rational means 
possible, replacing the same by saline intravenously 
or by colonic irrigations. Assist labor when it is 
developing or when the patient's condition does not 
improve. 

If actual operative measures are needed, provided 
there be no dilatation of the cervix, the choice of 
methods rests between abdominal csesarean section, 
vaginal caesarean section, and instrumental dilata- 
tion of the cervix. Vaginal caesarean section seems 
to offer the best chance for the mother in that it 
seems to involve the least shock and the least chance 
of sepsis. C. D. Holmes. 

Raab, F. H.: Indications for the Advantages of 
the High Incision in Caesarean Section. /. 

Mo. St. M. Ass., 1916, xiii, 76. 

The author gives the following indications for 
caesarean section: 

1. Absolute indications, i.e., conditions which 
admit of no other means of delivery: (i) contracted 
pelvis, as a flat pelvis where the true conjugate is 
less than 7 cm, and the child normal in size; (2) 
neoplasms of the pelvis, uterus, adnexa, cervix, 
vagina, rectum, if sufficient to cause obstruction to 
the birth canal so that a normal birth is prevented; 
(3) additional indications, cicatrices of the vagina, 
or cervix, some cases of ventral fixation, ruptured 
uterus, tonically contracted uterus, accidental 
haemorrhage; (4) eclampsia — by this method of 
treatment the maternal mortality has been reduced 
nearly one half; (5) placenta praevia is thus best 
treated, as it offers the best chance for both mother 
and child; (6) condition of the foetus — one with a 
non-moulding head, impacted breach or face, or 
prolapse of the cord, where infection has been 
avoided. 

2, Relative indications: These are cases where 
caesarean section vies with forceps delivery, podalic 
version, pubiotomy, accouchement force, etc. Such 
cases include pelvic deformity, certain cases of 



placenta praevia, tonic contraction of the uterus, 
some eclamptic cases, also moribund women where 
operation is done in the interest of the child, or to 
give temporary relief to the mother. 

3. Contra-indications (i) where attempts at 
delivery have been made from below; (2) where it is 
suspected that vaginal examinations have been made 
without aseptic precautions. 

Operation: Choice of time to operate. It is 
best to wait until labor has begun to be sure the 
foetus is mature. However, in a large per centage 
of cases the operation is an emergency operation. 
A high incision in the uterus is of distinct advantage 
for the following reasons: (i) the abdominal open- 
ing is smaller than in the low type of incision; (2) 
abdominal and uterine wounds are separated by 
contraction and involution of the uterus which 
lessens the chance of adhesions, (3) uterine incision 
is made through the part of the organ away from 
the layer of blood-vessels which lessens the danger 
of haemorrhage; (4) incision is made in a portion of 
the uterus less likely to rupture in future pregnancies; 
(5) there is less escape of intestines and omentum 
which lessens the shock and post-operative disturb- 
ances; (6) there is less probability of subsequent 
hernia. C. D. Holmes. 

Bell, R. G.: Caesarean Section in a Pitman's 
Cottage. Brit. M. J., 1916, i, 195. 

The author reports a caesarean section performed 
under unusual difficulties, in a case of contracted 
pelvis. The two previous labors had ended in the 
sacrifice of the children. Operation was successful 
in this instance, a living child was delivered, and the 
patient had a smooth convalescent puerperium. 
Exception might be taken to the opinion expressed 
by the author that many major abdominal opera- 
tions could be done quite as well at the patient's 
home as in the hospital. Certainly with the 
history of the case in hand transportation to the 
hospital could have been effected long before the 
time of the operation, the need for which was 
evident. Philip F. Williams. 

Tweedy, E. H.: The Lower Uterine Segment, 
Its Origin and Boundaries. Lancet, Lond., 1916, 
cxc, 565. 

It requires only a very minute portion of the upper 
portion of the cervix to sufl&ce for the growth of the 
lower uterine segment. We must think of the 
cervix as growing large rapidly rather than of its 
being rapidly stretched. These changes in the 
growth of the cervix result from stimulation by 
direct pressure exercised by the ovum during the 
latter half of pregnancy and during labor. To un- 
derstand the progress of the growth of the lower 
uterine segment, it is important to keep in mind 
certain established anatomical and physiological 
features. The endoperitoneal tissue forms an im- 
portant diaphragm for the pelvis. Its fibers are 
inserted into the muscle bundles of the uterus and 
may be considered the tendinous extremities of the 



8o 



INTERNATIONAL ABSTRACT OF SURGERY 



latter. The diaphragm is held in tension by the 
uterine muscle; it supports the uterus, prevents 
descent of the contents of the abdomen, and con- 
stitutes a barrier which effectively protects the cer- 
vix from pressure. The os internum opens at an 
early period of pregnancy and this relaxation corre- 
sponds with Hegar's early sign of pregnancy. 
Consequent on this opening the uterus and ab- 
dominal contents sag downward and the fornices 
become somewhat shallow. The uterine muscle- 
fibers are put out of tension by the opening of the os, 
with consequent contraction and retraction of these 
fibers and the upward movement of the diaphragm 
with its attached blood-vessels and ureter. This 
upward movement produces a still wider opening 
of the diaphragm, permitting the growing ovum to 
pass through it and allowing the latter to exercise 
direct pressure on the structures immediately 
beneath. Bearing these facts in mind we must 
conclude that the cervix is not an elastic structure, 
but, on the other hand, that it has a power of 
extraordinarily rapid growth when stimulated by 
continuous pressure. The similarity in the growth 
of the cervix to that of the growth of the lower 
uterine segment is very apparent, and we have no 
difficulty in following its subsequent development 
into the part known as the lower uterine segment. 
The ring of Mueller must be considered the undilated 
portion of the cervix which has as yet not been sub- 
jected to direct pressure, and Bandl's retraction 
ring must consist of the structures which go to form 
the internal os. C. D. Hauch. 

Irving, F. C: The Systolic Blood-Pressure in 
Pregnancy; Observations on Five Thousand 
Consecutive Gases in the Pregnancy Clinic 
of the Boston Lying-in Hospital. /. Am. M. 

Ass., 1916, Ixvi, 935. 

In 80 per cent of pregnant women, the blood- 
pressure ranges from 100 to 130. 

In 9 per cent, the blood-pressure may be below 
100 one or more times. A blood-pressure below 
90 does not mean that the patient will have shock 
unaccompanied by haemorrhage at confinement. 

In 1 1 per cent of cases, the blood-pressure may be 
above 130 one or more times. Age, nationaUty, 
■ and parity seem to have some influence on blood- 
pressure. High blood-pressure in the young is more 
frequently a sign of toxaemia than in those over 30. 

Elevated blood-pressure is more commonly an 
index of toxaemia than is albuminuria, and it is 
apt to be an earlier sign. The degree of elevation 
points more surely to the likelihood of toxaemia 
than does the degree of albuminuria. Both, how- 
ever, are of the utmost importance. 

Isolated cases of elevated blood-pressure unaccom- 
panied by albuminuria or evidences of toxaemia 
occurred not infrequently. Usually they responded 
to free catharsis. Some pressures remained elevat- 
ed in spite of treatment and apparently were nor- 
mal, during pregnancy at least, for the patients 
who exhibited them. 



A progressively rising blood-pressure, often from 
a low level, even though it never reaches the arbi- 
trary danger point, should be regarded with appre- 
hension as a most valuable sign of approaching 
toxaemia. Toxaemia is much more common with a 
blood-pressure above 150 than it is below that point. 

Most cases of eclampsia occurred with a pressure 
of 160 or more. Eclampsia may, however, occur 
with a moderately elevated blood-pressure. 

All toxaemics developed both albuminuria and 
elevated blood-pressure. 

While the incidence of eclampsia in this series is 
about the same as the figures usually given, it is 
significant that two-thirds of the patients who 
developed convuls'ons absolutely neglected advice 
and refused to return to the clinic. Had these pa- 
tients been discharged against advice during preg- 
nancy for disobeying instructions, very favorable 
statistics would have been obtained. The hospital 
feels that it would have been most unjust to the 
ignorant foreigners, who constitute the vast major- 
ity of its patients, to desert them when they most 
needed skilled hospital care. With proper co-opera- 
tion from the patients and eliminating the fulminat- 
ing cases which develop in a few hours, there is no 
doubt that eclampsia would be practically a pre- 
ventable disease. Edward L. Cornell. 

LABOR AND ITS COMPLICATIONS 

Wichmann, S. E. : The High Forceps Operation (Zur 
Klinik der hohen Zangenoperation) . Nord. med. 
Ark., Stockholm, 1916, Kirurgi, No. i, p. 11, and 
No. 2, p. 131. 

The author in a very detailed and comprehensive 
article deals with the clinical data obtained in 200 
high forceps operations in the obstetrical clinic of the 
University of Helsingfors from the beginning of the 
year 1890 to the middle of 1914. A short summary 
of each case is given. The matter is so diffuse and 
extensive that only an outline of the points discussed 
by the author can be presented in an abstract. 

Under the heading of material Wichmann dis- 
cusses: Choice of the cases; distribution of the 
material according to differences of maternal pelves; 
size of the children; the manner of presentation of 
head in pelvis; indications calling for high forceps 
operation; age of the mothers and number of labors. 

Under prognosis of high forceps operation, the 
following points are considered: 

1. For the mother: (i) mortality, (2) injuries, 
(3) post-partem haemorrhages, (4) morbidity, (5) 
late results. 

2. For the child: (i) mortality, (a) as regards 
the pelvis and weight of child, {b) age of mother and 
number of previous births, (c) indication for opera- 
tion, id) mobility or fixation of head; (2) causes of 
death of the children; (3) injuries, late results. 

The technique of the high forceps operation by 
various operators is discussed. Finally the value of 
the high forceps operation as regards position of the 
operation in the therapy of the contracted pelvis, 



OBSTETRICS 



8i 



and significance of the resistance of soft parts as 
regards prognosis for mothers and children in high 
forceps operations. The article is accompanied 
by an extensive bibliography. W. A. Brennan. 

Mundell, J. J.: Pituitrin in Labor. Am. J. ObsL, 
N. Y., 1916, Ixxiii, 306. 

The author has reviewed the rather extensive 
literature which has accumulated on this subject 
during the six years this extract has been used in 
obstetrics. He has collected reports of 3,952 cases 
in which it has been used and gives a table showing 
the unfavorable results which have been reported 
by various writers. There were 6 deaths due to 
rupture of the uterus, but in each case the records 
show that these fatal cases were due to the misuse 
of pituitrin. He finds a foetal mortality of 21 in 
3,952 cases and a maternal mortality of 7. 

This study shows the need of careful analysis of 
all the factors in the case before reporting the good 
or bad effects of such a powerful extract as pituitrin. 

C. H. Davis. 

Skeel, A. J. : Analgesia and Anaesthesia in Obstet- 
ric Practice. /. Am. M. Ass., 1916, Ixvi, 797. 

In labors not distinctly abnormal, morphine is 
used during the first stage, and only when the labor 
is expected to last at least four hours longer. The 
author's indications for morphine during the first 
stage are: 

1. A rigid, hypersensitive os. 

2. Evidence of considerable pain, with a probable 
first stage of several hours, as in most primiparae. 

3. The presence of nagging but ineffectual pains 
which irritate and exhaust the patient out of 
proportion to results. 

Accordingly, many patients, particularly primip- 
arae, get a single hypodermic of one-sixth grain of 
morphine. 

At the beginning of the second stage, or if the 
patient suffers severely, shortly before dilatation 
is completed, the use of gas is begun. Intermittent 
administration is made at first, that is, during the 
pain only, and with small amounts, as 30 gallons 
of nitrous oxide to 15 gallons of oxygen. As the 
head approaches the pelvic floor and finally strikes 
the perineum, the nitrous oxide is gradually in- 
creased in volume to 50 or 60 gallons and the inter- 
vals between administrations are shortened. This 
gradual increase of the volume of the gas given is 
controlled by 'the patient's statement of pain or 
comfort during uterine contraction. As the perine- 
um begins distending and the most painful stage of 
labor arrives, the gas is given still more continu- 
ously until, at the time of crowning, from 70 to 80 
gallons of nitrous oxide are given practically con- 
tinuously. When the head is born, the nitrous oxide 
is at once discontinued and the patient sharply 
revived by a few inhalations of pure oxygen. 

If the woman is a primiparae with a rigid, inelastic 
perineum and lacerations seem inevitable, the utmost 
possible relaxation is secured by switching to ether 



and pushing to complete unconsciousness at the 
moment the head crowns the perineum. 

The author enters a vigorous protest against the 
advice at present being so freely given that anyone 
may use gas in labor cases with perfect safety. Gas 
is a powerful therapeutic agent with infinite possi- 
bilities for harm at the hands of incompetent or 
careless users. The statement has been made that 
gas in the hands of an expert is a safe anaesthetic, 
but the most dangerous anaesthetic if given by a 
novice. This is far too strong a statement to make 
concerning analgesia. Even here, however, some 
knowledge and experience are necessary to secure 
both safety and satisfaction from its use. Moreover, 
the temptation to follow a gas analgesia labor with 
a gas anaesthesia for repair is so obvious that all 
those who expect to adopt this method should spend 
sufficient time in special study of the agents they are 
to use so that they can direct its administration. 
This does not mean that a doctor must equip him- 
self as a gas expert. The skill necessary for its use 
in labor can be acquired in a short time, but free 
use of gas by the absolutely inexperienced will 
surely lead to tragedies. Edward L. Cornell. 

MISCELLANEOUS 

Francis, L. M.: Treatment of Ophthalmia Neona- 
torum. Buffalo M. J., 1916, Ixxi, 344. 

The author not only discusses the treatment of 
ophthalmia neonatorum but also those features in 
its management which are of interest to the general 
practitioner. The article may be summed up as 
follows: 

1. Not all ophthalmias of the newborn are 
gonorrhceal; 30 per cent are due to other organisms, 
as the staphylococcus, streptococcus, etc. 

2. There are two classes of ophthalmias, those 
primary infections occurring at the time of birth, 
and those where the infection occurs secondarily 
from extravaginal sources. 

3. Early diagnosis is imperative. All new cases 
of ophthalmia must be regarded with suspicion 
until proven to be of a benign nature; smears should 
be made early. 

4. In unilateral infection, the other eye should be 
protected, and the attendants warned of the danger. 

5. Because of the frequent serious corneal involve- 
ment gonorrhceal ophthalmia should be under the 
care of the ophthalmologist. 

6. Careful and intelligent nursing is as important 
as medical advice in these cases. C. D. Holmes. 

Bamert, C. : Treatment of Gonorrhceal Ophthal- 
mia. Med. Rec, 1916, Ixxxix, 239. 

The author has used cresatin in a number of 
cases of gonorrhceal ophthalmia and finds it an 
excellent drug. Cresatin is a phenol derivative of 
very powerful germicidal properties, entirely free 
from the corrosive, destructive, action of the or- 
dinary phenols. 

The duration of gonorrhceal ophthalmia under 



82 



INTERNATIONAL ABSTRACT OF SURGERY 



this method of treatment is twenty-four to forty- 
eight hours after the first application. In most 
cases one application was found sufficient; in none 
were more than two such treatments given. Gono- 
cocci were rarely found after the first application; 
where they did so appear a second application 
effectively disposed of them. 

The technique is as follows: A 25 per cent solu- 
tion of cresatin in albolin is used. The conjunctival 
sac must first be cleared of secretion by means of a 
stream of warm physiological saline or saturated 
boric acid solution, preferably through an undine. 
This is followed by the instillation of a drop or two 
of a one per cent solution of holocaine or cocaine 
to prevent the slight irritation of the next step. 
A small cotton swab is used to apply a drop of cresa- 
tin to the mucosa of the conjunctival sac. It is 
imperative to cover the entire surface of the mucous 
membrane in this application. The after-treat- 
ment consists in keeping the conjunctival sac free 
from pus, and the repetition of the application, 
should occasion demand. Ralph H. Ktjhns. 

Hannah, C. R.: Injuries to the Infant, Produced 
at Birth. Texas St. J. Med., 1916, xi, 539. 

The author discusses the various causes for birth 
injuries, and gives the histories of four cases of 
long and difficult labor followed by injuries to the 
infants. 

It is in cases of contracted pelvis that the in- 
fants suffer most. Here the use of the forceps pro- 
duces a depressed fracture, a concussion of the brain, 
or an intracranial haemorrhage, any one of which 
may cause a permanent pathological change which 
in later life may explain paralysis, headache, 
epilepsy, and other existing maladies. Usually 
these injuries are the result of the unscientific ap- 
plication of the mechanics of delivery; brute force 
is substituted for proper and thoughtful manipula- 
tions. Prolonged and hard labor pains, which pre- 
vent a change in the foetal blood, are frequently 
found in cases of generally contracted pelvis, and 
in cases with rigid and unyielding perineum. 

In conclusion, the author emphasizes the following 
points : 

That neglect of frequent observance of the 
foetal heart-sounds costs the life of many a child. 

That a slow irregular foetal heart-beat or an ex- 
cessively fast one signifies foetal danger. 

That the presence of lumpy or sea-green meco- 
nium in the Uquor amnii in cephalic presentation 
may mean compression, and failure to recognize 
this fact hazards the life of the foetus. 

That pituitrin may cause tetanic contractions 
of the uterus, and if so, an interchange in the 
placental blood may be prevented, which would 
produce hypercarbonization. 

That an irregular and slow foetal heart, or an 
excessively fast one, or the presence of meconium 
in the liquor amnii, are symptoms which indicate 
that the foetus must be delivered or it will probably 
die. 



That if an attempt to deliver is made it should 
first be made certain that the child can be delivered 
alive, and that it will probably live and, second, 
that the mother will not be injured. 

That an internal haematoma, causing internal 
pressure, should be removed early or pathological 
destruction of the nervous system will take place, 
which may cause deformities, imbecility, epilepsy, 
and other forms of degeneracy. Ralph H. Kuhns. 

Davis, E. P. : Syphilis in Its Relation to Obstetrics. 

Tr. Am. Gynec. Soc, Washington, 19 16, May. 

Davis believes that the most positive diagnosis of 
syphilis in the parturient woman and her offspring 
is made by recognizing spirochaetse. These para- 
sites are found in the walls of the umbiHcal vein 
and in the connective tissue of the umbilical cord. 
This gives an opportunity for examination in 
suspected cases without exposing mother or child, 
or arousing alarm or suspicion. The parasites are 
never found in the amnion, but occasionally in the 
chorion. When found in the placenta they are in the 
villi and in the walls of these tissues. Should the 
resistance of the placenta be successful, they will 
probably be destroyed by the cells of the villi. 

Syphilis may be diagnosticated from the placenta 
when gummae, placental abscess, or marked over- 
growth of the connective tissue of the placenta is 
present. Normally, the comparative weight of the 
placenta and child is as i : 6, while in syphilis the 
proportion is 1:4, indicating the marked increase 
in size of the syphilitic placenta. Where the mother 
is syphilitic, although the child escapes, the spiro- 
chaetae are found in the cord in over 50 per cent of 
cases, and where both parents are syphilitic, the 
placenta shows evidence of their presence in 70 
per cent. Syphilis is transmitted from foetus to 
mother through the leucocytes of the umbilical 
vein, or through ruptured vessels of the villi. So far 
as fcetal infection by syphilis is concerned, the pa- 
ternal element is much less important than was 
previously supposed. 

The spirochaetae are found abundantly in the or- 
gans of the syphilitic foetus, and are present in 
three-fifths of all macerated foetuses. 

Where the spirochaetae can be found in the blood 
of either parent, or in tissues removed from lesions, 
the diagnosis is positive. Searching for the para- 
sites, the fact must be kept in mind that bichloride 
of mercury, i : 5,000, causes the parasites to disappear 
from tissues, and hence care must be taken lest 
antiseptic precautions destroy the possibility of 
diagnosis. 

Syphilis may form antigens in the milk, which 
protect against active infection. The mother is then 
especially well prepared to nurse her offspring which 
may be, and probably is, syphilitic. Should the 
child be syphilitic and the mother absolutely sound, 
a syphilitic nurse should be secured for the child, 
but if the mother be syphilitic and the child healthy, 
the child should be artificially fed. In doubtful 
cases, it is best to procure a healthy wet nurse. 



OBSTETRICS 



83 



The majority of writers today believe that CoUes' 
law is no longer valid in view of our present knowl- 
edge. The condition known as latent syphilis in the 
mother, the antigens which her breast milk contains, 
and the belief that the foetus conveys syphilis to the 
mother, are proof against the validity of CoUes' law. 

Treatment may destroy spirochaetae, but unfor- 
tunately toxines produced by the parasites may still 
poison the patient. 

The Wassermann reaction cannot be relied upon 
for a positive diagnosis of S5T)hilis. Pregnant 
patients having diseases caused by protozoa or 
tuberculosis, malignant growths, scarlatina, pneu- 
monia, and eclampsia, may give a positive Wasser- 
mann reaction when syphilis is absent. It has fre- 
quently been observed that a patient having a 
negative Wassermann reaction is greatly benefited 
by antisyphilitic treatment. 

Noguchi's vaccine, known as luetin, is useful in 
preventing the development of tertiary syphilis. 
It has not been especially successful with pregnant 
women. 

The frequency of syphilis among parturient 
w^omen is difficult to estimate. Fournier found that 
among married women in his clinic, 70 per cent had 
syphilis before marriage, and 40 per cent afterward. 
In the majority, the first signs of the disease appear 
within six months after marriage. When histories 
could be obtained, it was found that the husbands 
had become infected less than three years before 
marriage. The first three years after marriage is 
the most dangerous period of life for the woman so 
far as infection by syphilis is concerned. Both 
syphilitic men and women should receive continu- 
ous treatment for at least six years before marriage. 

In parturient patients syphilis may cause lesions 
in the genital tract, making spontaneous birth diffi- 
cult or impossible. The mortality of syphilitic or 
parturient women is estimated at 73 per cent, 
largely from mixed infection. Puerperal morbidity 
is much increased by syphilis, and nephritis may 
develop in the puerperal period. 

It is commonly supposed that syphilis is a frequent 
cause of abortion, but this is now being denied. 



In the living newborn, a diagnosis can be made 
by examining the umbilical cord, and detecting 
characteristic parasites in the walls of the umbilical 
vein and connective tissue. In apparently healthy 
children, spirochaetae are often found about the 
umbilicus. The X-ray is especially valuable for it 
shows in the newborn the osteochondritis which is 
an important symptom of the disease. Syphilis is a 
frequent cause of sudden death in frail, ill-nourished 
infants, in whom there may be no apparent sign of 
the disease. Children born with syphilis may 
remain apparently healthy, and develop disease of 
the joints, the lymphatics, the bones, and the cornea, 
as late as eight years after birth. Both knees are 
often attacked, and the bilateral character of the 
disease differentiates it from tubercular disease of 
the knee-joints which is unilateral. In these cases 
the synovial fluid may give a positive Wassermann 
test. 

Seven per cent of syphilitic children die before the 
end of the first year, and among such tuberculosis 
develops in 12 per cent. 

As regards the frequency of syphilis in the new- 
born among the poor, Fildes found one infant in 
1,015 to be syphilitic at birth, among the poor in the 
east end of London; 3.9 per 1,000 among the women 
gave a positive Wassermann reaction. Pemphigus 
of the newborn is by many not considered 
a syphilitic, but a streptococcus infection. The 
characteristic lesions are found in the palms of the 
hands, in the soles of the feet, and in the peculiar 
staining of the tissues about the mouth and the 
anus. 

Salvarsan treatment is useful for both mother and 
child in acute and florid syphilis, but it will not 
prevent the death of the child in utero from toxaemia. 
The majority of observers use salvarsan for acute 
and severe cases, and rely upon mercury and iodine 
to complete a cure. In using salvargan, the urine 
should be repeatedly examined to observe the excre- 
tion of arsenic. Should this fail, poisoning may 
result. Many prefer to treat the pregnant woman 
by hypodermatic injection of a mercurial prepara- 
tion. 



GENITO-URINARY SURGERY 



ADRENAL, KIDNEY, AND URETER 

Thomas, G. J.: Clinical Review of 240 Cases of 
Non-surgical Infection of the Kidneys and 
Ureters. Urol, b" Cutan. Rev., 1916, xx, 127. 

The author analyzes 240 cases of renal infection 
which received urological treatment in the Mayo 
Clinic. Tuberculosis and infection secondary to 
calculus or urinary obstructions are excluded. 
Frequency of urination is the earliest and most 
frequent symptom, 76 per cent. Cystitis, however, 
was noted in only 16 per cent of the cases. Renal 
pain was the initial symptom in 37 per cent, and 
haematuria in oiily 7 per cent although present at 
some time in 41 per cent. Ninety-five cases had 
bacteriologic examination and 63 per cent of these 
were colon infections. Thomas argues that the 
original "offending organisms probably lessen the 
resistance of the kidney so that the colon bacillus 
which is constantly passing through the kidney be- 
comes pathogenic." The majority of infections are 
bilateral and should be considered so until proven 
otherwise by pyelography and cultural exmination. 
Contamination is frequent, usually from poorly 
sterilized ureteral catheters or the use of an unsterile 
lubricant. 

In treatment, a careful search for foci of infection, 
such as tonsils, teeth, abscesses, furunculosis, 
bone infections, etc., should be made before urologic 
treatment is instituted. Of local treatment, lavage 
of the kidney pelvis and ureters every four or five 
days was most frequently used; lavage with 0.5 to 
3 per cent silver nitrate. Of 150 cases which were 
followed, in 29 per cent the condition remained 
stationary, improved in 46 per cent, and cured in 
18 per cent. Of the 28 cases cured, 6 had auto- 
genous vaccine only; 6, vaccine and urinary antisep- 
tics only; 4, urinary antiseptics only; 2, pelvic lavage; 
and 2, vaccines and lavage; whereas, 2 cases had 
urinary antiseptics, vaccines, and lavage. Three 
cases received no treatment, 2 were operated upon, 
and one had bladder lavage only. Frank Hinman. 

Crabtree, E. G.: A Method of Demonstrating 
Bacteria in Urine by Means of the Centrifuge; 
the Relative Value of Examinations by Culture 
or Stained Sediment. Surg., Gynec. & Obst., 
1916, xxii, 221. 

The author caUs attention to certain unavoidable 
errors in the diagnosis of urinary infection where 
the clinician relies entirely upon cultural evidence. 
These errors are due to four factors: 

I. The tendency of some common bacteria like 
the colon bacUlus when recurring in mixed infections 
to overgrow other perhaps more significant bacteria. 



This occurrence is most troublesome in bladder 
infections with phosphatic calculi and in coccus in- 
fections of the kidney where a colon pyelonephritis 
already exists. 

2. The tendency of chromogenic bacteria to ob- 
scure other more significant growths in mixed cul- 
ture. 

3. The possibility of formalin sterilization of 
small quantities of urine being washed down from a 
formalin sterilized catheter sufiicient in quantity 
to inhibit growth in culture. 

4. Routine culture fails to demonstrate some of 
the more rare bacterial infections because of un- 
suitable cultural conditions and media. 

He calls attention to the value of .stained sediments 
as a control to cultural examinations of infected 
urines as a means of avoiding the above errors. 
By his method of eliminating pus from the centri- 
fuged sediment large numbers of bacteria, including 
tubercle bacilli when present, are demonstrated. 
Sufficient evidence as to the nature oFthe infecting 
organisms is obtained by stained cover-glass pre- 
parations to indicate proper cultural procedures. 
Contaminations are readily recognized from true 
infections by the number of bacteria obtained. 

Schmidt, L. E.: The Role of Urine Stasis in the 
Etiology of Pyogenic Kidney Infections. 

Lancet-Clin., 1916, cxv, 118. 

Urine stasis is probably the most important 
factor in establishing renal infection. It is generally 
recognized that, if lowered resistance of a kidney be 
present, urine stasis may account for pathological 
changes in the kidney and the sequelae which occur. 
Bacterial invasion may take place by these means 
through the ureters or their lymph-channels, pro- 
vided that an infectious focus exists in the bladder 
or the immediate neighborhood. Recent investiga- 
tions have undoubtedly demonstrated the existence 
of a lymph-channel between the bladder and kidney 
by way of the ureter, and this route is, according to 
the author, the most important source of ascending 
renal infection. 

Owing to predisposing factors existing in women, 
such as periods of congestion of their genital organs, 
superinduced by menstruation, pregnancy, and 
labor, the possibility of the establishment of colon 
infections of the kidney is greater than in men, and 
Schmidt believes that this type of infection, al- 
though some statistics state the contrary, is more 
frequently met with in the female sex. 

Owing to the close relation of the intestinal tract 
to the kidney by lymphatic circulation, colon in- 
fections of the kidney are. easily accounted for, which 
generally occur on the basis of intestinal congestion 



84 



GENITO-URINARY SURGERY 



85 



and stasis. In the etiology of urine stasis congenital 
renal anomalies of formation or location (horseshoe 
kidney, dystopias with anomalous vessels favoring 
stone-formation, polycystic kidney, etc.) play an 
important role. Schmidt has observed that many 
of these conditions are the nucleus for later occurring 
renal infections. In 11 cases of congenital poly- 
cystic kidney, which came to operation, 9 were com- 
plicated with infections. The same is true of 
hydronephrosis, in the vast majority of which, 
infection sooner or later necessitates operative 
interference. 

Operative injuries of the ureter, obstructive con- 
ditions connected with advanced renal neoplasms, 
parasitic growths of the kidney, and concrements of 
the upper urinary tract are cited as other and 
frequent sources for renal stasis and consecutive 
renal infection. In looking over his operative 
records, the author found that urine stasis in the 
pelvis of the kidney was an important factor in 
infections of the kidney, that in fully four-fifths of 
his cases the colon bacillus could be demonstrated 
as the infecting agent, and that but a small per- 
centage of cases are ascending in character. 

Owing *to the fact that obstructive conditions of 
the urethra are more prevalent in males, consecutive 
infectious changes of the upper urinary tract are 
less frequent in women than in men, a fact that is 
borne out by the author's statistical compilation of 
his own material. 

The reverse is true of urine stasis due to pathologi- 
cal conditions in the bony pelvis, causing pressure on 
the ureters, which are by far more common in the 
female sex. The greater frequency of renal infec- 
tions in the male, as evidenced by the author's 
statistics on his own work, is explained on the basis 
of the preponderance of more favorable conditions 
for general infections in that sex. 

The author concludes his very instructive article 
by insisting upon early operative relief for the great 
majority of cases of renal infection as a sequel to 
urine stasis. A more expectant regime may yield 
good results in the frequent cases of colon infection 
consecutive to congestion, while in renal infections 
due to the more common pus-producing organisms 
only active surgical measures are fraught with satis- 
factory results. M. K rotoszyner. 

Danziger, F. : An Unusual Case of Kidney Ripping 
by a Grenade Splinter (Ein ungewoehnlicher 
Fall von Nierenzerreissung durch Granatsplitter) . 
Berl. klin. Wchnschr., 1916, liii, 160. 

Danziger gives a short clinical report of a very 
interesting and unusual case of ripping of a kidney 
by a splinter of a grenade. On operation the kidney 
was found to be completely torn in two pieces, the 
ureter which was also torn from the bladder being 
attached to the smaller piece. The wound cavity 
was cleaned out and tamponed, the ureter removed, 
and the vessels in the vicinity ligated. The 
peritoneum was not injured. After a few days the 
tampon was withdrawn and the edges of the torn 



kidney united and sutured. The haemorrhage was 
slight and there were no complications. Recovery 
was uneventful. W. A. Brennan. 



Stutzin and Gundelfinger: War Injuries of the 
Urogenital System (Kriegsverletzungen des 
urogenital Systems). Deutsche med. Wchnschr., 
1916, xlii, 188, 227. 

Stutzin, who writes from the German Red Cross 
Hospital at Constantinople, discusses the most 
frequent type of injuries of the genito-urinary 
system occurring in war. He gives the details of the 
clinical history in ten cases of this kind observed 
by him. He points out the difficulty of carrying 
out the complicated diagnostic and operative tech- 
nique required in such cases at the front; but says 
that cystoscopy is possible and necessary in the 
field.^ 

Injuries of the bladder are the most frequent 
type observed. Where the healing is tardy incision 
and drainage must be resorted to. 

In the case of ureteral fistulae occurring from 
wounds without spontaneous healing, nephrectomy 
is called for. Sectioning of the bladder is generally 
the rule in the case of urethral injuries. Plastic 
operations are often required on the genital organs 
and when necessary the scrotal skin is best utilized. 
The after-treatment of all cases operated upon for 
urogenital injuries must be carefully watched. 

W. A. Brennan. 

Kakels, M. S.: Large Congenital Hydronephrosis 
in an Infant Six Weeks of Age. N. Y. M. J., 

1916, ciii, 547. 

Kakels reports this case on account of its rarity, 
the youth of the patient, the large size of the hy- 
dronephrosis, its rapid progress, and its successful 
removal by transperitoneal nephrectomy. 

The infant was six weeks old, ventricose from 
birth, and since birth a gradual and increasing swell- 
ing of the abdomen had been noted. On examina- 
tion the whole abdomen was found to be greatly 
distended, with the swelling bulging from under the 
costal borders on both sides, and toward the right 
flank an elongated mass was felt, with fluctuation. 
The diagnosis lay between a malignant and non- 
malignant growth of the kidney and was corrob- 
orated by the X-ray plate which showed that it was 
a retroperitoneal growth. 

On account of its large size, the growth was ex- 
tirpated transperitoneally, through the anterior 
abdominal route, and 900 ccm. of straw-colored 
uriniferous fluid was removed. The sac showed 
that it was continuous with a greatly enlarged kid- 
ney (three times its normal size) made up entirely 
of a distended pelvis, of globular form, and not pear- 
shaped. There was neither stricture nor dUatation 
of the ureter, but from its obliquity of entrance and 
its anomalous position the author considered these 
factors the etiological element in the causation of 
the hydronephrosis. Louis Gross. 



86 



INTERNATIONAL ABSTRACT OF SURGERY 



Ransohoff, J.: Unilateral Haematuria. Surg., 
Gynec. b'Obst., 1916, xxii, 275. 

Ransohoflf presents a case of pancreatic cyst, 
with what he believes to be the unique symptom of 
haematuria. The tumor was in the left upper 
quadrant, projecting into the loin, distinctly fluc- 
tuating and of slow growth. When first seen it was 
nearly as large as an adult head. Cystoscopic 
examination showed a bloody stream of urine issuing 
from the left ureteral orifice. Indigocarmine injec- 
tion demonstrated equal function on the part of 
the two kidneys. 

Ureteral catheterization and radiographing of the 
renal pelvis was refrained from on account of the 
weakened condition of the patient at the time of 
examination. The barium injection of the rectum 
showed the colon normal. 

Exploration of the left kidney by lumbar incision 
revealed a somewhat larger kidney than normal. A 
diagnosis was made of cystic sarcomata of the left 
kidney. Lumbar exposure of the kidney showed it 
to be normal. Median incision then displayed the 
cyst of the pancreas, projecting between the colon 
and the stomach, with the spleen six or eight times 
its normal size. The pressure of the pancreatic 
cyst on the renal and splenic vein had produced 
the haematuria and the enlargement of the spleen. 
The haematuria disappeared after the operation. 

So far as the author knows, the case is unique, 
since a search of the relevant literature has failed 
to show another case. 

The pancreatic matter of the cysts was demon- 
strated by the presence of the three pancreatic 
ferments: alkaline proteinose, amylose, and lipose. 
There were also present little masses of saponified 
fat. 

Macedo, C. : The Periods of Amelioration in Renal 
Tuberculosis (Los periodos de mejoria en la 
tuberculosis renal). Cr6n. m6d., Lima, 1916, 
xxxii, 33. 

From clinical histories the author deducts that 
during the long periods of arrest or apparent cure of 
renal tuberculosis, some symptoms improve and 
even disappear, while others persist, revealing the 
existence of the primitive pathologic state of the 
kidney. 

The symptoms diminishing in intensity or dis- 
appearing are: (i) lumbar pain; (2) frequency of 
micturition; and (3) haematuria. 

The clinical signs which persist are: (i) polyuria; 
(2) albuminuria; (3) pyuria; and (4) bacillus tuber- 
culosis. 

Cystoscopic examinations have proved to the 
author that — (i) acute cystitis of a tubercular 
origin may develop into a chronic state, with a 
normal functioning of the urinary bladder; (2) 
cicatrices of advanced tubercular lesions may be 
observed; (3) in such conditions characteristic 
cystoscopic aspects are met with. 

Renal tuberculosis starts insidiously and develops 
without being discovered by the patient or the 



attending physician; then it confines itself to lesions 
of the renal parenchyma, latent tuberculosis. 

When the patient has reached the stage of acute 
tuberculosis, producing symptoms alarming to the 
patient and permitting of a diagnosis, the tubercu- 
lous process is sufficiently advanced to force the 
abandoning of all hope for a spontaneous cure or 
medical treatment; the end-result is the destruction 
of the kidney. Although renal tuberculosis and 
long living are incompatible, the only salvation of 
life in such cases rests with the surgeon, nephrectomy 
being the only treatment available, with the under- 
standing that all depends on the condition of the 
other kidney and the general condition of the 
patient. Raoul L. Vioran. 

Simmonds, M.: Danger of Pyelography (Ueber eine 
Gefahr der Pyelographie) . Muenchen med. 
Wchnschr., 1916, Ixiii, 229. 

In a case in which Simmonds made a pyelographie 
investigation for doubtful kidney symptoms, the 
patient died on the third day following. In this 
case 15 cm. of a 5 per cent coUargol solution 
were injected into the right kidney pelvis. He 
reviews some other reported cases of death follow- 
ing coUargol solution injections. 

From the autopsy made in his own case it is clear 
to Simmonds that coUargol poisoning was not the 
cause of death, but that death resulted from a 
streptococcus septic invasion. There were apparent- 
ly erosions in the ureter by which the streptococci 
had found a mode of entrance into the blood stream. 
While it is not clear what part the injection may 
have played in the passage of the microbes, yet a 
S per cent solution was evidently not bactericidal. 

Among the dangers of pyelography therefore 
must be reckoned one that is usually ignored, i.e., 
septic infection. The surgeon must take special 
precautions to avoid injuries to the kidney tissues 
by the infusion, and if the bladder or lower urinary 
passages are found to contain infective microbes it 
is better to abstain from pyelography. 

W. A. Brennan. 

Grossi, v.: Clinical Considerations of Ambard's 
Constant (Applicazioni cliniche deUa constante 
di Ambard). Foliclin., Roma, 1916, xxiii, sez. 
chir., 41. 

Grossi has made an extensive study of the clinical 
results obtained by himself and others in the applica- 
tion of Ambard's constant. His own experience 
is based on 51 complete clinical cases in which the 
constant was observed 77 times. He concludes 
that Ambard's urosecretory constant is like various 
other methods of value in examining the renal func- 
tion, indicating the global alteration of the function 
of the kidney; and that it can in its extreme limits 
confirm a lethal prognosis or cause more caution in 
making an operatory intervention. It is superior 
to the calorimetric method in cases where catheteri- 
zation of the ureters is impossible. 

In regard to the numerical limitations imposed by 



GENITO-URINARY SURGERY 



87 



Chevassu, Grossi believes that they have no ab- 
solute value and that the interpretation of the con- 
stant ought be made in each individual case accord- 
ing to the clinical criteria and the various causative 
factors: azotemia, ureic concentration, daily 
ureic elimination. 

In 5 patients dying from renal insufficiency the 
azotemia was always higher than i gram; in one 
case it reached 5.2 gr. per 1,000; in one case for 
some few days before death it fell to 0.3 gr. Three 
cases in which the azotemia was above i gr. were 
operated upon successfully and recovered; i died 
four months later. 

The ureic concentration in cases of death was 
always below 10 per 1,000. The daily elimination 
was stUl less and was associated with oliguria. In 
2 patients dying from haematogenous infection of 
the kidney the constant and its factors were almost 
normal. 

From the surgical point of view great value should 
be attached to the ureic concentration and to the 
daily elimination, which correspond in reality to 
Albarran's two-hour examination of the global 
urine and to Cathelin's analogous procedures. 

The significance and pathogenesis of the azotemia 
and of the constant are very far from being clear. 
In their present state Grossi thinks that we must 
consider them as simply signs to which it is necessary 
to attach great importance, perhaps just as much 
as to the albumin contents of the urine. 

W. A. Brennan. 

Wechselmatin : Intravenous Injections of Lactose 
Without Reaction: Sclayer's Kidney Test 

(Ueber reaktionslos verlaufende intravenoese 
Milchzucherinjectionen). Berl. klin. Wchnschr., 
1916, liii, 84. 

Wechselmann has been using the lactose test for 
some years past and in many thousands of cases. 
His experience is that it is very reliable when the 
lactose is pure and furnishes a dependable index of 
the kidney functioning. The ill effects which some 
have found after the use of lactose are explainable 
as due to the presence of impurities. 

W. A. Brennan. 

Wyman, M. H.: The Phenolsulphonephthalein 
Estimation of Renal Function in a Thousand 
Cases. /. So. Car. M. Ass., 1916, xii, 84. 

The majority of the 1,000 tests were done on 
surgical patients at the Columbia (S. C.) Hospital, 
as a part of the routine examination. 

An output of 70 per cent or over comes only 
from normal kidneys. 

A 60 per cent output may be temporarily observed 
in cases where there are at the same time evidences of 
kidney disease, albumin, or casts, but if the latter 
do not clear up quickly, the output soon begins 
to decrease. 

When a sound kidney is compensating unusually 
well for its diseased fellow, we may find a 60 per 
cent excretion together with albumin and pus. 



But in 95 per cent of cases evidence of kidney dis- 
ease is accompanied by an excretion below 60 per 
cent. 

From the prognostic viewpoint the important 
thing is whether the curve rises or falls. A man 
may be regarded as a good surgical risk with an 
output of but 20 per cent, provided the curve has 
risen and is stationary. F. E. Gardner. 

Runner, G. L.: Ureteral Stricture; Excluding 

Cases Due to Tuberculosis and Calculus; 

Report of Fifty Cases. Tr. Am. Urol. Ass., 
St. Louis, 1916, April. 

In discussing stricture of the ureter, the author is 
dealing only with the narrowing of the ureteral 
lumen due to intrinsic disease of the ureter. 

The report of cases is further limited by excluding 
strictures due to tuberculous disease and those 
strictures immediately surrounding a stone. 

Thus Hmited, inflammatory stricture is a far more 
common disease than formerly believed, the author's 
cases up to November, 191 5, numbering 50 as 
contrasted with 49 nephrectomies for tuberculosis 
and 39 operations for stone in the ureter. 

The author recognizes congenital narrowing as an 
etiological factor in the disease, but thinks its im- 
portance has been greatly overestimated and does 
not classify any of his cases as due to this cause. 

Other causes are gonorrhceal infection probably 
traveling up the lymphatics from the bladder, and 
pyelonephritic infections which others have con- 
sidered as infecting the ureter by way of the urine 
stream. The author thinks it more probable that 
the ureteral wall involvement is synchronous with 
the pyelonephritic infection and, like it, has a blood or 
lymph stream origin. 

Ureteral stricture from the ordinary pyogenic 
cystitic infections is extremely rare. Traumatic 
cases follow operations, childbearing, and other 
sources of injury to the ureteral wall. 

The author thinks that by far the greatest source 
of ureteral stricture is some distant focus of disease 
such as infected tonsils, sinuses, teeth, or disease of 
the gastro-intestinal tract. 

In such cases the disease settles in the ureteral 
walls and causes the narrowing which in many cases 
is followed by dilatation and later by infection of 
the urinary tract. 

The symptoms of ureteral stricture are, for the 
most part, due to the obstruction and are identical 
with the symptoms of stone in the ureter. Some 
patients complain only of a more or less constant 
dull, aching pain in the lumbar region. Others have 
this constant dull pain with acute exacerbations of 
pain in the kidney region, and the pain is often re- 
flected down the ureter. There may be bladder 
and rectal tenesmus. Such attacks may require 
morphia, and either the pain or the morphia may 
bring about severe nausea and vomiting. 

If infection be present, the above symptoms are 
likely to be more severe and are accompanied by 
chills, high temperature, and profound prostration. 



88 



INTERNATIONAL ABSTRACT OF SURGERY 



The congestions incident to exposure, getting the 
feet wet, "catching cold," and those due to the 
menstrual period, are likely to cause partial or 
complete temporary closure of the inflammatory 
area and to thus bring about a severe attack of 
renal pain. Spontaneous local pain at the stricture 
site is complained of in some cases 

The diagnosis is made on the history, the urine 
examination, and the physical findings. As above 
stated, the history is that of stone in the ureter or of 
pyelitis. The urine may be quite negative, but it 
usually contains a few red blood corpuscles or 
a few leucocytes, and it may contain both in small 
or large numbers. Particularly after a severe renal 
colic, the urine may be smoky with blood, or if in- 
fection be present it may be turbid with pus and 
bacteria. 

The observation that the urine may be quite 
negative in these cases is a most important one from 
the diagnostic standpoint. Too often with a nega- 
tive X-ray and with normal urine it is concluded 
that the urinary tract is not involved and renal 
catheterization and the obtaining of a pyelo-uretero- 
gram are neglected. The patient is operated upon 
for appendicitis, or some form of exploratory lapa- 
rotomy is done, and the victim continues to suffer 
or to find partial relief in expectant methods of 
treatment. 

If the stricture be located in or near the bladder 
wall, it may be palpated as a definite thickening 
indistinguishable from the infiltration usually 
surrounding a stone, and cystoscopy in such a case 
often shows redness and oedema about the ureteral 
orifice. 

If with the above history and urinary and physical 
findings, one is unable by X-ray and a wax-tipped 
catheter to locate stone in the ureter, a probable 
diagnosis of stricture is justified. 

Repeated obstruction to the renal catheter at a 
certain distance from the bladder is further evidence 
of stricture. 

By melting pure beeswax and making a wax 
spindle on the renal catheter at a short distance 
back of its tip, one can appreciate the obstruction 
to this spindle as it meets the stricture, and a more 
certain diagnostic feature is the "hang" of this 
spindle on the stricture area as the catheter is with- 
drawn. 

Additional corroborative evidence of stricture is 
the presence of a hydronephrosis, although a mea- 
surable increase in kidney and ureter content may 
be absent even after years of recurrent renal at- 
tacks. 

The trauma of catheterization is often followed by 
a severe renal attack and in the infected cases by a 
typical pyelitis attack. In suspected ureteral stone 
or stricture a large catheter, or preferably a large 
catheter with wax bulb dilator, should be passed to 
dilate sufficiently to avoid this oedematous closure 
of the lumen after examination. 

The author has seen several cases in which the 
fluid content of the kidney pelvis was less than 



normal. These are usually cases with a prolonged 
infection which has resulted in contraction of the 
kidney pelvis in spite of the mechanical obstruction 
lower down causing symptoms. A pyelo-uretero- 
gram in such cases shows the site of the ureteral 
stricture and a slightly dilated ureter above this 
point. 

The author takes definite issue with the prevailing 
opinion that dilatation of the kidney pelvis and 
ureter are due to infection. Many of his cases 
with sterile urine and no history of previous infection 
have the dilated ureter and pelvis. 

Of 44 cases with urine report, i6 were sterile; and 
of these i6, ii have notes on the kidney content : 3 
of these were approximately normal, measuring re- 
spectively 8, II, and 12 ccm.; 7 had a hydronephrosis 
ranging from 15 to 30 ccm., and one exceptional 
case with clear urine measured 385 ccm. 

Of 18 infected cases, 15 were measured, 4 being of 
normal or less than normal size, and the pelvis in 
II cases averaging 130 ccm. In this series of cases 
the average duration of symptoms in the sterile 
cases was two and a half years, and in the infected 
cases four years. 

The ideal treatment for stricture of the ureter is by 
dilatation from the vesical approach. Dilatation 
results in relieving the patient's symptoms and in a 
shrinkage of the distended pelvis and ureter. If 
infection be present, dilatation is supplemented by 
renal lavage, although it is probable that many 
cases would clear up without the lavage simply by 
giving the urine free drainage. In the infected 
cases of long duration, with immense sacculated 
kidneys, one may be unable to clear up the infection, 
but after dilatation of the stricture the kidney 
pelvis shrinks markedly, the urine becomes much 
more clear, and in some cases entirely clear except 
for the bacteria and microscopic pus, and the pa- 
tient is restored to approximately normal health. 
These facts are of vital importance to those patients 
with bilateral stricture. In the cases with mono- 
lateral stricture and with immense hydronephrotic or 
pyonephrotic kidney, conservatism often calls for 
the extirpation of the kidney. This was done in 
six of the author's cases. 

In cases that cannot be dilated by the vesical 
approach, the author advises extraperitoneal ex- 
posure of the ureter and retrograde dilatation. 
This was done on 8 of his 50 cases, with excellent 
results in 6. Two of his early cases failed to obtain 
complete relief, probably because of insufficient 
dilatation. 

Bilateral stricture was demonstrated in 12 of the 
50 cases. It is probable that systematic examina- 
tion would have shown a larger percentage of bilat- 
eral cases, as some of these 1 2 had symptoms on one 
side only, and the other side was accidentally shown 
to have stricture in the course of a functional 
test; or after relief of symptoms on one side the 
patient returned later with symptoms in the other 
kidney, and these were found due to stricture in 
the corresponding ureter. 



GENITO-URINARY SURGERY 



89 



BLADDER, URETHRA, AND PENIS 

Woodall, G. W.: Some Problems in the X-Ray 
Diagnosis of Urinary Calculi. Albany M. Ann., 
1916, xxxvii, 116. 

According to Woodall, the X-ray is but one of 
three indispensable means of diagnosis in cases of 
suspected urinary calculi. The other two are: 
(i) a careful history and physical examination; (2) a 
cystoscopic exploration and study of the urinary 
findings from the bladder and kidney. 

He groups the cases from a roentgenologic view- 
point into three classes: 

1. The X-ray findings may be positive and 
easily confirmed by cystoscopic and other- data. 

2. The X-ray findings may be negative and very 
misleading unless subordinated to other available 
positive data. Negative cases may suddenly be- 
come positive, due probably to some change in the 
composition of the calculi. 

3 . Apparently positive X-ray findings may prove 
to be erroneous when checked by cystoscopic and 
other means of diagnosis. 

Several case histories are given to illustrate each 
group. 

Woodall considers the X-ray to be the most 
valuable single factor in the diagnosis of urinary 
calculi and to be of indispensable service when used 
in conjunction with a carefully taken history and 
exhaustive study of the clinical aspects of the case. 
Used alone, however, without proper confirmation by 
such means as mentioned, it may lead to serious 
error almost as often as it would furnish a correct 
diagnosis. David R. Bowen. 

Kelly, H. A., and Neill, W,: Cauterization and 
Fulguration of Bladder Tumors. /. Am. M. 

Ass., 1916, Ixvi, 721. 

The author reports two cases in which cauteriza- 
tion and fulguration were done for bladder tumors. 

The first case, a female, aged 41, had been twice 
operated upon for papilloma of the bladder, five 
and four years previous, respectively. Two years 
previous, cystoscopy had revealed an ulceration 
26 mm. in diameter on the posterior wall. There 
was a similar area on the vertex 18 mm. in diameter. 
Repeated fulgurations, covering a period of eighteen 
months, cleared up numerous tumor masses. At 
present the bladder is normal except for two small 
recurrent areas about 4 and 2 mm. in diameter 
about the right ureteral orifice. 

In the second case, a female, aged 38, the cystos- 
copy revealed a large papilloma attached to and 
filling the anterior surface of the bladder. Cystot- 
omy showed a growth 1.5 cm. in diameter attached 
to the posterior wall and three large cauliflower 
growths on the anterior wall protruding into the 
urethra and including the left ureteral orifice. 
Nine tumors in all were removed. There was a 
recurrence two years later the size of a cherry near 
the left ureteral orifice, but after fulguration there 
was no recurrence. 



The authors advocate the aerocystoscope (Kelly), 
its advantage being that it facilitates seeing and 
treating the pedicle of the tumors, thereby shorten- 
ing the period of treatment. There are also two 
slightly diverging needles for fulguration. With 
the open cystoscope a curved sickle-shaped 
platinum knife is used. It is hooked around the 
pedicle and when heated is brought forward through 
the pedicle. H. A. Kraus. 

Freund, H.: Experience with Makka's Operation 
for Ectopia of the Bladder (Unsere Erfahrungen 
mit der Makkas'schen Operation der Blasenek- 
topie). Beitr. z. klin. Chir., 1916, xcix, 99. 

In a very comprehensive paper the author re- 
views a number of original operations by various 
authors and their modifications, citing the advan- 
tages and disadvantages of these procedures in 
detail. Essentially all operations are considered 
under two headings, grouped according to funda- 
mental differences in the technique of the operation: 
(i) In the first group the operator selects the intes- 
tinal tract for disposal of the urine. (2) In the 
second group the operator has in view the formation 
of a new bladder, having no connection with the 
intestinal tract. In these differences and char- 
acteristics lie the advantages and the dangers of the 
various procedures. The advantages ^nd dangers 
of the various operations of Trendelenburg, Maydl, 
Borelius, etc., are given in detail. 

The technique of the Verhoogen-Makkas opera- 
tion is described, especially the Makkas operation. 
This operation consists essentially in utilizing the 
caecum as a bladder and the appendix as an ureter. 
The modifications which have been suggested to 
avoid an ascending infection are referred to. The 
details are given of 5 cases operated upon by the 
Makkas method, including the author's case. 

The only serious obstacles which might prevent 
the Makkas operation from being carried out are: 
(i) the fact that the appendix may have been re- 
moved previously; or (2) in cases where the appen- 
dix as the result of inflammatory processes may have 
become so altered as to be valueless; furthermore 
(3) the caecum may be fixed normally or by inflam- 
matory adhesions. Freund describes some means 
of obviating these complications. Against the 
disadvantages there are numerous decided ad- 
vantages. 

In summing up his experience Freund concludes: 
(i) Age should be considered; one should not 
operate on a child under five without serious reasons. 
(2) A period of from six to eight weeks should elapse 
between the two steps of the operation, i.e., the 
preparation of the caecum and appendix and the 
removal of the exstrophied bladder. (3) Ureteral 
catheterization and analysis of the specimens prior 
to operation is important. (4) If pyelonephritis of 
both sides already exists, operation is not advised. 

Although in several cases the operation has been 
a failure, yet Freund is of the opinion that this is 
due to the fact that it was not confined to a single 



90 



INTERNATIONAL ABSTRACT OF SURGERY 



operator, but that in these cases there were two or 
three different operators. He further thinks that 
the results obtained in the cured cases are such as 
to lead to the belief that the Makkas operation is 
the operation of choice in bladder ectopia. 

W. A. Brennan. 

MacKenzie, D. W. : Double Urethra with Opera- 
tion; Review of Literature. Surg., Gynec. &" 
Obst., 1916, xxii, 344. 

The case reported from the genito-urinary service 
of the Bellevue Hospital was that of a young man 
26 years of age, who was admitted to the service in 
November, 1914. 

The patient had been troubled with enuresis 
nocturna at times since a child; had always passed 
urine from two openings, one in the normal position 
on the glans penis and one in the fraenum. About 
1903 a small lump appeared on the center of the 
ventral surface of the penis. It was cut down upon 
and a stone one-half inch in diameter removed 
from the urethra. The sinus still remained. 
About six months later a perineal section was per- 
formed. This opening also refused to close. 

Physical examination showed a well-developed, 
healthy young man, 5 feet 10 inches in height, weigh- 
ing 150 pounds; urinary meatus normal in size and 
position; sinuses, three in number, one at the 
fraenum, one about 1.5 inches from the fraenum on 
the ventral surface of the penis, and one in the 
perineum. 

Rectal examination showed no abnormalties. 
X-ray of the urinary tract was negative for stone. 
Cystoscopic examination revealed a normal blad- 
der with a small sacule into which the right ureter 
opened. The phenolsulphonephthalein output was 
normal. 

Exploration with probes and sounds revealed the 
existence of a urethra apparently normal except 
for a slight stricture in the bulb admitting a 26 F. 
sound. Of the three fistulae, the posterior perineal 
one opened into the membranous urethra just 
behind the stricture. The other two, at the fraenum 
and near the scrotum, opened into a common pas- 
sage which readily took a 26 F. sound and entered 
the urethra in the bulb just in front of the stricture. 

The perineal sinus was excised, and its opening 
to the membranous urethra closed. The subja- 
cent canal was slit from the fraenum ^to the bulb. 
It was found to be lined with normal mucous mem- 
brane, and surrounded, with its companion urethra, 
by a common corpus spongiosum. It was extirpated 
completely from the bulb forward. The wound 
healed by primary intention, and the patient left 
the hospital passing all his urine through the normal 
passage. 

The male urethra originates from two genetically 
distinct portions of the embryo, the prostatic and 
membranous portions resulting from the urogenital 
sinus, while the remaining portion originates at a 
later period from the folds of the genital ridge or 
tubercle. 



There are two important points to be settled, 
according to Lebrun: (i) Is the abnormal canal a 
urethra or merely some diverticular or canalicular 
excretory formation? (2) Granted it is a true 
urethra, how is its formation to be explained? 

MacKenzie's conclusions after studying a large 
number of cases are briefly as follows: 

The occurrence of more or less complete duplication 
of the male urethra, involving the canal from the 
bulb to the meatus, cannot be doubted, as a large 
number of well-authenticated instances of several 
degrees of the anomaly have been recorded. Ac- 
cessory canals have been described as being about 
equal in size to the normal urethra and freely com- 
municating with it in the bulb, as in Meisels' and 
the author's case. In others one passage was 
smaller than its fellow with which it connected, or 
ended in a cul-de-sac. Perfectly authentic cases 
of accessory urethras extending to the bladder have 
also been reported. 

The pathogenesis of all urethral duplications 
meets with difficulties, and many explanations have 
been suggested, the most probable theory referring 
the formation of a double urethra to anomalies of 
the epitheUal urethral strand in the embryo. 

GENITAL ORGANS 

Smith, E. O.: Anatomy and Pathology of the 
Seminal Vesicles. Urol, b' Cutan. Rev., 1916, 
XX, 76. 

The author's report is based on a study of a 
large amount of post-mortem material and brings 
out many points of practical value to the genito- 
urinary surgeon. 

In his series Smith found the greatest variation 
in size and position of the vesicles, and that their 
angle of divergence from the midline varies in dif- 
ferent individuals and in the same individual ac- 
cording to the degree of distention of the bladder. 
Most of the vesicles at their upper pole overlap the 
ureter where it enters the bladder; it thus follows 
that chronic inflammation of the vesicles at this 
point may constrict the ureter, make ureteral cathe- 
terization difficult or impossible, and by back pres- 
sure lower the resistance of the kidney to infection. 

The main blood supply of the vesicle enters at 
the upper and lower poles, consequently careful 
ligation should be done at these points in removing 
the vesicle. The peritoneum occasionally was found 
to extend well down on to the vesicle and the danger 
of entering the peritoneal cavity should be borne in 
mind in operating in this vicinity. 

From the clinical standpoint the most important 
feature of the vesicle examined by Smith was the 
presence of multiple sharp angulations in the tubule 
offering very poor natural drainage. This shows 
that massage of the vesicles to be effective should 
avoid trauma and that satisfactory surgical drain- 
age can only be secured by multiple incisions. In 
seeking for a source of "focal infections" the vesicles 
should never be overlooked. 



GENITO-URINARY SURGERY 



91 



Calculi were not found in any of the vesicles 
examined by the author and from his experience he 
does not believe that because a vesicle is nodular 
it is necessarily tuberculous. H. L. Sanford. 

Plaggemeyer, H. W.: Tuberculosis of the Seminal 
Vesical and Epididymis. Urol. &* Ctitan. Rev., 
1916, XX, 134. 

Tuberculous infection in the genito-urinary tract 
is^as a rule secondary to a focus elsewhere in the 
body, usually in the lungs, intestines, or bones. 
Primary tuberculosis of the genital tract has been 
demonstrated by a number of observers. 

Guisy in 183 cases of urogenital tuberculosis 
found 10 cases involving the prostate and seminal 
vesicles alone. Saxtorph in a series of 205 cases 
noted 9 such occurrences. Walker found that 
the disease was stated to be primary in genito- 
urinary organs in 52 out of 174 cases; but he found 
in experimental infections that the lungs were nearly 
always involved and showed the most advanced 
process. 

Generally speaking, genital tuberculosis is rare 
before the fourth month, the percentage increasing 
to a maximum in the third and fourth decade. 

In early life both sides are often affected, but after 
12 the majority of cases are unilateral. In Barney's 
series of 153 cases of epididymal tuberculosis, 
35 per cent were right, 35 per cent left, and 30 per 
cent bilateral. 

The great mass of evidence points to the epididy- 
mis as the most common seat of primary infection 
in the genital tract. Cabot says, " We should recog- 
nize that urinary tuberculosis is primary in the 
kidney and genital tuberculosis primary in the 
epididymis." Walker found in 279 cases that the 
kidney was first involved in 184, the epididymis in 
80, the prostate in 6, and the seminal vesicles in 2. 
Keyes holds that the weight of evidence goes to 
show that in many if not all cases the prostate 
or vesicle is tuberculous before the epididymis be- 
comes so. There is much authentic evidence that 
the epididymis is in most cases affected first. 

Whether the normal seminal vesicle can harbor 
the cast-off tubercle baciUi without being affected, 
or whether its secretion has a deleterious influence 
upon these organisms is as yet an unsolved problem. 

Considering the rarity of primary infection of the 
seminal vesicle and the developmental analogy of the 
seminal vesicle and the urinary bladder, the method 
of attack upon the kidney in bladder tuberculosis 
suggests the same rule in the vesicles and epididymis. 

Much argument and many experiments have been 
put forth to prove extension of infection in each 
direction, via the vas, some holding that extension 
can take place only in the direction of the current, 
and others that a reserved parastatitis is produced 
by irritation. Ascension by the subepithelial 
lymphatics and the blood stream helps to explain 
the passage of the disease upward without general 
involvement of the vas. Ascension seems to be the 
rule; descension the exception. 



When tuberculosis involves the epididymis above, 
epididymectomy should be performed. If both 
epididymes are involved, double epididymectomy 
is indicated. Masculinity is not impaired, and 
sterility has usually already taken place. 

It is questionable if orchidectomy ever is indicated. 

When both epididymes and testes are involved, 
it is better to incise and drain. The removal of a 
massively involved vas, if advisable at all, is best 
done by the high operation of Cabot. Removal of 
the epididymis and contiguous portion of the vas has 
had a signal effect on the process in the vesicles, 
the infection receding and the vesicles becoming 
fibrous. 

If the process is confined to the vesicle, vesiculec- 
tomy as advocated by Young is a splendid operation, 
but if the prostate also is involved it should not be 
performed. 

The prognosis of primary tuberculosis of the gen- 
itals in children is usually good, there seeming to be 
a limitation of tubercular processes in all organs 
in children except the meninges. In later life the 
tendency to wider involvements is a strong argu- 
ment for radical operation. 

Hygienic and climatic treatment both pre- and 
post-operative is of importance. The author favors 
the Corbus idea of active immunization before 
operation. 

The conclusions reached in the report of the 
Massachusetts General Hospital is that until 
ten years has elapsed no patient can be said to be 
cured of tuberculosis. 

In conclusion, genital tuberculosis in the male 
is a grave affection, and, except in the case of chil- 
dren, operation affords the best means of cure. 

The primary focus being removed, the survival 
of the patient depends on the ability of his body to 
immunize itself against the disease. H. G. Hamer. 

Staley, R. W.: Treatment of Non-tuberculous 
Inflammations of the Seminal Duct. Urol. &* 
Cutan. Rev., 1916, xx, 131. 

Surgical treatment of acute epididymitis has 
received considerable attention in recent years. 

Epididymotomy is a simple operation and can 
be done in the office under local anaesthesia. Pain 
is relieved promptly and resolution takes place more 
rapidly than by the expectant plan of treatment. 
Mild cases usually resolve fairly promptly under 
palliative treatment. The more severe cases 
justify epididymotomy. Relapsing epididymitis, 
not dependent upon prostatic, seminal vesicles or 
posterior urethral infection, are most successfully 
treated by total extirpation of the affected epi- 
didymis. 

Acute deferentitis usually yields to palliative 
treatment and rarely demands surgery except when 
abcess formation takes place, in which case drainage 
should promptly be instituted. 

The inaccessibility of the seminal vesicles and 
prostate has prevented more frequent use of sur- 
gical measures in acute conditions of these organs. 



92 



INTERNATIONAL ABSTRACT OF SURGERY 



On this account palliative measures must sufi&ce 
in the milder cases, and surgery be reserved for 
cases of well-defined abcess. Fuller's incision 
or that of Young and Squier will be necessary 
to reach the vesicles, while a slight modification of 
lateral lithotomy will be sufl&cient in the case of 
prostatic abcess. 

Non-operative treatment of acute prostatitis 
and vesiculitis includes rest in bed, application 
of heat by means of the psychrophore, restricted 
diet, antipyretic. All urethral manipulations 
should be omitted except catheterization when 
letention occurs. After acute symptoms subside, 
massage is indicated, and in the declining stage 
dilatations of the posterior urethra are of definite 
value. 

Irrigations of the vas, ampulla, and vesicle with 
argyrol or protargol by Belfield's method is helpful 
in those cases where much debris is expressed by 
massage. In perivesiculitis with impotence, not 
improved by massage or irrigations through the 
vas, a carefully performed vesiculotomy sometimes 
will restore the sexual function. 

Gonorrhoeal arthritis is relieved in many instances 
by non-surgical measures, but vesiculotomy or 
vesiculectomy may be necessary for permanent re- 
lief in some cases. Vaccines, bacterial derivatives, 
and phylacogens have been generally disappointing. 

The conclusions are: Epididymotomy represents 
a decided advance in the treatment of acute epididy- 
mitis. Dilatation, massage, and irrigation will 
benefit and control the majority of cases of prostato- 
vesiculitis. Irrigation of the vesicle through the 
vas in properly selected cases is curative. . Vaccines 
have some brilliant successes to their credit, and 
should still have a place in the treatment of these 
disorders. H. G. Hamer. 

Silverberg, M . : The Prognosis of Prostatitis. Calif. 
St. J. Med., 1916, xiv, 60. 

There are two methods of determining the con- 
dition of the prostatic gland: (i) its palpation 
through the rectum and (2) the gross and micro- 
scopic examination of the fluid expressed from the 
gland. He states that the palpation of the diseased 
gland may be misleading in that it may be perfectly 
smooth and of uniform consistency, but is usually 
slightly more sensitive to touch than the normal 
prostate. Irregularities in the size and shape of the 
gland are relatively common and are hard to inter- 
pret. In the microscopic examination of the ex- 
pressed secretion the presence or absence of pus- 
cells and their relation to the number of lecithin 
bodies present should be noted. These findings are 
subject to the following errors: (i) the distribution 
of the pathological elements may be uneven and 
the material used in the examination may be from 
the normal portion of the gland; likewise the marked 
involvement of a small focus may furnish enough 
pus to diffuse throughout the entire specimen and 
the error would be made of diagnosing a diffuse 
disease of the gland; whereas in reality there is 



present only a small focus of disease. The third 
factor in determining the prognosis is the reaction 
of the patient to the various treatments. 

The author states that these conditions some- 
times clear up without treatment, but usually do 
not. Most of the cases persist with a marked 
obstinacy. He states that after a given method of 
'treatment has been used for a few weeks if the pa- 
tient does not improve the method should be 
changed either in whole or in part and this plan 
should be persisted in until a method suitable for 
that particular case is obtained. The author 
summarizes as follows: 

1 . It is desirable that prostatitis be cured in every 
case, but treatment frequently fails or is otherwise 
unsatisfactory. 

2. The outlook is an important matter to the 
individual as well as from the standpoint of social 
hygiene prophylaxis. 

3. The probable issue is suggested by the history, 
clinical findings, and by closely following the effects 
of treatment. 

4. There is really no scientific method of establish- 
ing prognosis, though bacteriology may avail here. 

5. The duration of treatment is uncertain. 

V. D. Lespinasse. 

McCarthy, J. F.: Some Features of Importance 
in the Diagnosis and Prognosis of Urogenital 
Tuberculosis. Surg., Gynec. &" OhsL, 1916, xxii, 
330. 

The author calls attention to the importance, in 
urogenital tuberculosis, of investigating the deep 
urethra as well as the bladder. He comments on the 
frequency (hitherto insufficiently emphasized) of 
the associated involvement of the urethral structures 
even in the presence of unilateral renal tuberculosis. 

Attention is also called to the fallacy of operative 
procedure such as epididymectomy, etc., without 
the most careful inspection of the posterior urethra. 

The author feels that, while it is generally recog- 
nized by urological surgeons that operative inter- 
vention such as nephrectomy, etc., for tuberculosis 
should be regarded merely as the preliminary step 
in the treatment of a constitutionally tuberculous 
subject, altogether too little emphasis is accorded 
this fact in operative clinics as well as the hospital 
care of such cases. 

Finally, he emphasizes the supreme importance 
of universal state care of the "surgical" tubercu- 
lous, non-operative and post-operative subject, 
from the economic and humanitarian standpoint. 

MISCELLANEOUS 

Hanzlik, P. J.: Hexamethylenamine as a Urate 
Solvent and Diuretic, and Its Effect on the 
Reaction of Urine. J. Lab. &" Clin. Med., 1916, 
i, 321. 

The author exhaustively reviews the literature 
in order to find the truth about the alleged urate 
and uric acid solvent properties of hexamethylena- 



GENITO-URINARY SURGERY 



93 



mine. The chemistry and behavior of various so- 
called urate solvents indicate only very slight 
chances of success under the conditions existing in 
the body. 

Urate or uric acid solubility depends largely on the 
degree of reaction (hydrogen-ion concentration) 
and the concentration of fluids, and there is no 
evidence to show that hexamethylenamine has 
any particular influence in this respect. 

Recent and reliable evidence shows definitely 
that therapeutic doses of the drug impart to the 
urine no demonstrable uric acid or urate solvent 
qualities. Excessive doses impart only slight and 
practically negligible solvent effects. A greater 
action would be obtained at a much lower cost 
with any of the common alkaline diuretics. 

There is no evidence that hexamethylenamine can 
dissolve urate calculi. 

No substance has yet been discovered which 
would form either soluble or easily oxidizable com- 
pounds with uric acid, under the conditions obtain- 
ing in the body. F. E. Gaiujner. 

Zobel, A. J.: Genito-Urinary SjTnptotns Arising 
from Anal, Rectal, and Colonic Diseases, and 
Vice Versa. /. Am. M. Ass., 1916, Ixvi, 496. 

Ulcerative conditions in and about the anal region, 
such as fissures, chancres, chancroids, and perianal 
eczemas are reflexly the cause of frequent and pain- 
ful urination. In acute proctitis, in acute dysen- 



tery, and in the presence of inflamed and ulcerated 
haemorrhoids, there is sometimes reflex dysuria and 
vesital tenesmus due solely to an irritable rectal 
condition. Cancer of the rectum is usually so in- 
sidious in its growth that an anuria may be one of the 
first symptoms of the disease. A syphilitic stricture 
of the rectum is also apt to be quite insidious in its 
formation, and may give rise to scarcely any rectal 
symptoms, even though it has developed a consider- 
able degree of constriction of the bowel. 

Abnormalities in the urine resulting from colonic 
conditions solely, are occasionally met with. Trans- 
parietal infection through the lymphatics from the 
intestine may be the cause of a cystitis. An en- 
largement of the inguinal glands occurs with chancre 
of the anus. Urethral stricture, polypi in the 
urethra, especially of the deep urethra or its adnexa, 
phimosis, stone in the bladder, gonorrhoea in women, 
and enlargement of the prostate gland, are some of 
the more common reflex causes of anal itching. On 
the other hand, the author states that he has seen a 
very severe scrotal and perineal pruritus caused by 
lesions entirely within the anal canal. 

Neoplastic growths of the bladder, prostate, and 
seminal vesicles may give rise to rectal symptoms 
such as are common in the early stages of rectal 
cancer. In consequence of abscess formation from 
disease or injury to the genito-urinary tract, a 
fistulous tract opening into the rectum is very 
liable to result. H. A. Moore. 



SURGERY OF THE EYE AND EAR 



EYE 

Verhoeff, F. H. : Rosacea Keratitis and Certain 
Other Forms of Marginal Keratitis, Neuro- 
pathic in Origin; Treatment by Pericorneal 
Neurotomy. Arch. Ophth., 1916, xlv, 148. 

Not generally known is the fact that with acute 
coryza and gastro-intestinal disturbances, herpetic 
lesions limited to the periphery of the cornea and of 
a highly distinctive character may occur. 

The author contends that as they are uniformly 
located 1..5 mm. from the limbus, this shows that 
they occur at the terminations of the conjunctival 
nerves in the cornea, and lesions situated 3 or 
4 mm. from the limbus are explained by assuming 
that some nerve branches extend unusually far. 

Since it is generally accepted that facial herpes is 
neuropathic in origin, it is regarded as altogether 
probable that these peripheral corneal lesions are 
likewise so, and the author's explanation of neuro- 
pathic keratitis in general is that impulses from the 
aflFected ganglion cells pass backward along the 
ordinary sensory nerves to the nerve terminations 
in the cornea, where they produce, by electrolytic 
dissociation, toxic substances injurious to the tis- 
sues. 

Rosacea keratitis is also regarded as a form of 
neuropathic keratitis, and acting on the above 
theory the author does a partial peritomy to in- 
terrupt the injurious impulses, with the result 
that in fifteen cases operated on during the past 
year he has secured prompt healing in all, with no 
recurrences. 

Rosacea of the skin, being regarded as an angio- 
neurotic condition due to some abnormal constituent 
of the blood, he correlates with the corneal lesions 
by assuming that the same deleterious agent acts 
on the gasserian ganglion and through this on the 
skin and cornea. S. S. Howe. 

Dehogues, T. L. : Treatment of Gonococcic Con- 
junctivitis by Autogonococcic Serum (Trata- 
miento de la conjuntivitis blenorragica por el 
suero antigonococico). Rev. d. med. y cir. de la 
Habana, 1916, xxi, 99. 

The author reports 8 cases successfully treated. 
The first hypodermic injection of the serum con- 
sisted of I ccm. Subsequent injections of 2 ccm. 
were made every three or four days. After the 
fifteenth day of treatment no gonococci were found 
in the secretions. Corneal ulceration was found 
in one case, but was slight and yielded to special 
treatment. There were no phenomena of anaphy- 
laxis, and no nervous symptoms. 

W. A. Brennan. 



EAR 

Smith, S. M.: Aural Complications of Influenza. 

Therap. Gaz., 1916, xl, 165. 

Otitic influenza like other inflammatory changes 
due to the bacillus of influenza is distinguished by 
the intensity, rapidity, and virulence of action, 
frequently involving the mastoid and other adja- 
cent structures, with absence of the usual symptoms. 
The initial observable inflammatory process is a 
severe myringitis, haemorrhagic in character, with 
spontaneous rupture of the membrana tympani in 
forty-eight hours. Early free incision of the mem- 
brana tympani with rest and general eliminative 
treatment are the best prophylactic measures. 

Ellen J. Patterson. 

Packard, F. R.: Report of a Case of Acute Mas- 
toiditis, with Influenzal Meningitis; Treat- 
ment by Operation on the Mastoid and 
Anti-influenzal • Serum. Tr. Am. Otol. Soc, 
Washington, 1916, May. 

The patient, a young girl, eleven years old, fol- 
lowing severe chilling, developed what was apparent- 
ly a grippy attack and an acute otitis media in her 
right ear. The author incised the membrana 
tympani and evacuated some pus and the next 
day she had distinct symptoms of a mastoid in- 
volvement, accompanied by some stupor, marked 
Kernig's sign, photophobia, and muscular rigidity 
of the neck. The mastoid was opened and at the 
same time a lumbar puncture was performed. The 
fluid withdrawn from the spinal column showed an 
influenzal bacilli. Flexner's anti-influenzal serum 
was injected into the spinal column. Several such 
injections, each of which was followed by marked 
improvement in the patient's condition, were used 
in the course of the week subsequent to the mastoid 
operation and the development of the meningeal 
symptoms. The child's mastoid wound did 
well, the meningeal symptoms practically subsided 
and marked drowsiness developed, with a re- 
currence of the symptoms of meningeal irritation. 
The diagnosis of abscess of the temporosphenoidal 
lobe was made and the cranium opened and pus 
evacuated. The child then made an uninterrupted 
recovery. 

Dench, E. B.: Acute Mastoiditis with Unusual 
Symptoms Indicative of Intracranial Involve- 
ment; Operation; Recovery. Tr. Am. Otol. Soc, 
Washington, 1916, May. 

The patient, a young woman aged 17, was op- 
erated upon for mastoiditis on the eighth day after 
the inception of an acute otitis media. The 



94 



SURGERY OF THE EYE AND EAR 



95 



mastoiditis was found to be of the haemorrhagic 
variety. Convalescence was slow, and six weeks 
after the operation the patient was again admitted 
to the hospital suffering from severe headache, gen- 
eral neurasthenic symptoms, and mental depression. 
At this time there appeared also an abducens paral- 
ysis upon the affected side. There was no evidence 
of any labyrinthine involvement, and no aphasia, 
the spinal fluid was negative, and the ophthalmo- 
scopic examination showed each ocular fundus 
normal. 

On account of the severe headache, a large area 
of dura was exposed in the middle cranial fossa, and 
the dura stripped up from the floor of the middle 
fossa as far as the apex of the petrous pyramid. 
No extradural collection of pus was found, and no 
collection of pus was found in the old mastoid wound. 
The patient made a complete recovery. The head- 
ache immediately disappeared, and the abducens 
paralysis disappeared. A rubber tissue drain had 
been inserted deep in the middle cranial fossa at 
this operation. Three days after the operation, 
swelling of each optic papilla was noticed — more 
marked upon the operated side. The rubber tissue 
drain was removed, and the optic neuritis rapidly 
disappeared. 

While the case presents many of the symptoms 
first described by Gradenigo, it differs from them in 
that in these cases some purulent focus has usually 
been found at the time of operation, the presence of 
which explained the symptoms. In this particular 
case, no such focus was found. It seems probable 
to the author that the cause of the unusual symp- 
toms was a low grade of inflammation spread- 
ing along the dura to the apex of the petrous pyra- 
mid, as an area of dura in the middle fossa was ex- 
posed at the time of the mastoid operation. This 
meningeal inflammation probably caused a certain 
amount of pressure upon the gasserian ganglion and 
also upon the sixth nerve, causing the severe neural- 
gic pain in the head and the paralysis of the sixth 
nerve. 

Dench, E. B.: Obscure Cases of Mastoid Involve- 
ments. -V. V. M. J., 1916, ciii, 529. 

This report does not deal with cases where the 
diagnosis is so evident that it can be made by a 
glance at the patient, but rather with those cases 
in which the development of the inflammatory 
process is so insidious and the symptoms so slight 
that a diagnosis is made with the greatest diflaculty. 

The author reports several cases in which the 
middle-ear condition had cleared up or was rapidly 
clearing up, but in which the inflammatory process 
in the mastoid was rapidly progressing as was dem- 
onstrated by the operation. From such cases the 
author draws the conclusion that the actual ces- 
sation of discharge is no absolute indication that 
the mastoid is healthy. Such being the case, the 



author attempts to show how one can tell in a given 
case of acute aural suppuration that there will 
probably be serious mastoid involvement, or how 
one can tell in a given case that any involvement 
has entirely disappeared when the middle ear has 
completely recovered. 

The following diagnostic signs are mentioned: 

1. As to the site of the inflammatory process 
the author states that inflammations confined to the 
lower part of the tympanic cavity are much less 
liable to be followed by serious mastoid infection 
than cases in which the upper part of the cavity is 
involved. 

2. As to the duration of the discharge, the author 
believes that middle-ear involvement which does 
not resolve very definitely at the end of two weeks 
is one of mastoid involvement sufficiently extensive 
to demand at least exploratory operation. 

3. Concerning tenderness on pressure over the 
mastoid the author states that tenderness at the 
beginning does not mean much, but tenderness 
after the fourth or fifth day is of great significance, 
and he adds that tenderness over the antrum is of 
more significance than tenderness over the tip. 

4. The nature of the discharge is of importance, 
as a streptococcus infection is more likely to result 
in mastoid infection requiring operation than is a 
staphylococcus infection. 

5. The sign upon which the author places most 
reliance is a narrowing of the external auditory 
meatus near the drum. 

6. Another important canal sign is an actual 
shortening of the external meatus, a condition in 
which the entire drum membrane appears nearer to 
the entrance of the canal than under normal con- 
ditions. 

7. The above signs acquire additional importance 
where the opposite canal is normal in caliber and 
length. Concerning the swelling of the canal caused 
by furunculosis the author notes that this narrowing 
is more superficial than the narrowing due to mastoid 
involvement. When in doubt the author opens 
the mastoid. 

8. Roentgenograms are mentioned as of great 
assistance. 

9. The general symptoms mentioned as of diag- 
nostic importance are persistent headache and sleepn 
lessness. 

As to temperature and the differential blood 
count, the author is not much influenced by their 
absence. 

In closing, the author cites a case illustrative 
of the diagnostic importance of recurring attacks of 
acute otitis in pointing to mastoid involvement. 
The author feels that this sign needs more careful 
consideration as he argues that these attacks would 
not recur unless a purulent focus existed somewhere 
in the deeper structures of the middle ear. 

Otto M. Rott. 



SURGERY OF THE NOSE, THROAT, AND MOUTH 



NOSE 

Veasey, G. A.: The Diagnosis and Treatment of 
Inflammatory Affections of the Nasal Accessory 
Sinuses. Northwest Med., 1916, xv, 73. 

After alluding to the importance of sinus disease 
as a causative factor in many gastro-intestinal af- 
fections, as well as toxaemias affecting other portions 
of the body, the author considers the sinuses collec- 
tively and mentions the well-known symptoms of 
headache, tenderness, nasal obstruction and dis- 
charge, dizziness and vertigo, as well as aprosexia 
and neurasthenic symptoms in general. 

As to diagnostic methods the author mentions 
transillumination as one of the best aids. Other 
aids, as the pharyngoscope, X-ray, puncturing and 
irrigating the antrum, and the application of suction 
to the nose, are favorably commented upon. 

As to treatment of the acute condition, the author 
mentions the necessity of securing adequate drain- 
age and ventilation, and this is secured by shrinking 
the nasal mucosa by the application of a weak solu- 
tion of cocaine instead of adrenalin, as the latter is 
apt to produce a secondary swollen condition 
greater than was primarily present. After the 
membrane has been shrunken, the author cleanses 
with a normal saline solution or with a mild alkaline 
solution followed by an application of a 25 per cent 
solution of argyrol and an oil spray. The patient 
is instructed to douche his nose freely with hot 
normal saline solution every hour or two, and to 
take deep inhalations every two or three hours of 
compound tincture of benzoin and menthol, four 
ounces of the former and one drachm of the latter, 
two tablespoonsful being used in one-half pint of 
boiling water. General treatment with calomel, 
saline, aspirin, and phenacetin is recommended. 

The indication for the treatment of the chronic 
cases is likewise, drainage, whether obtained by the 
correction of obstructing septal deformities or hy- 
pertrophied turbinates. After drainage has been 
obtained irrigations are advised and when these 
prove futile, operative interference is justified. The 
author has little faith in the beneficial influence of 
autogenous vaccines. Otto M. Rott. 

Gatewood, W. E.: Garcinomata of the Naso- 
pharynx. /. Am. M. Ass., 1916, Ixvi, 499. 

From a review of the literature, the following 
points are gleaned: 

Garcinomata of the nasopharynx are characterized 
by a rather long latent period and most of them 
originate in the vault or on the posterior wall. They 
are more prone to ulcerate and lead to epistaxis than 
other malignant tumors of this region. Extension 



may take place in four ways: (i) by the inferior or 
pharyngeal route; (2) by lateral prolongation; (3) 
by the anterior or nasal route; (4) by the posterior 
or cranial route. 

Garcinomata of the nasopharynx very rarely 
produces visceral metastases; but as a rule they 
give earlier adenopathy than other tumors of this 
region. About 60 per cent of the carcinomata in 
this region occur in individuals between 40 and 60 
years of age; but they have been noticed in children 
as young as 13, 16, and 17. Otto M. Rott. 

Molina-De Saint Remy, A. H.: Migraine. N. Y. 

M. J., 1916, ciii, 588. 

Migraine is nasal in origin being 4iie to pressure 
upon the sphenopalatine ganglion, caused by 
swelling of the mucosa of the middle turbinate 
impinging against a relatively high deviation of 
the nasal septum which disturbs the local circula- 
tion and ends in a reflex spasm of the cerebral vessels. 
The treatment indicated is thorough and complete 
submucous resection of the nasal septum with care 
to avoid perforations. Ellen J. Patterson. 

Gallison, J. G.: Papilloma of the Nose. Laryngo- 
scope, 1916, xxvi, 153. 

The author reports a case of a true papillary 
fibroid in a colored woman, aged 40, which had 
been of 12 years' duration and previously operated 
upon. When first seen by the author, the left 
nostril was filled with a growth which presented a 
dry, dark, and wrinkled appearance. The nasal 
cavity was so completely filled with the growth that 
a snare could not be passed around it, much less 
the site of origin determined. To effect removal a 
biting forceps was used, and thus its origin from the 
lower border and external surface of the middle 
turbinate was determined. Microscopical exam- 
ination revealed the nature of the growth. Of 
particular interest was the appearance of the 
epithelial cells, which retained their columnar 
character even to the surface. Other features of 
interest in the histological sections were the intense 
purulent infiltration of the epithelium and its ab- 
sence from the connective-tissue stroma, the 
pus-cells in places collecting into groups and form- 
ing cystlike spaces. 

The growth had a tendency to recur, so in order 
to eradicate as thoroughly as possible the base of 
origin and hence to evert the danger of malignant 
change, the author intends performing a Galdwell- 
Luc operation, followed by a radical Mosher opera- 
tion. After this, careful cauterization of the 
tissues with a chemical substance such as trichlora- 
cetic acid will be made. Otto M. Rott. 



96 



SURGERY OF THE NOSE, THROAT, AND MOUTH 



97 



Dabney, V.: Deaths Attributable to Intranasal 
Operations and Other Instrumentation. Surg., 
Gynec. &Obst., 1916, xxii, 324. 

Deaths following cauterization of the nasal mu- 
cosa, diagnostic puncture, and irrigation or mere 
perflation of the antrum of Highmore are not to 
be expected, but it is surprising that more deaths 
do not follow probing of sinuses, resecting the 
septum, or removing the middle turbinate, in part 
or in its entirety. Polypi removal is more danger- 
ous than believed for the same reasons, as they 
indicate deep-seated disease and periostitis. In- 
fection is accounted for by the virulence of the 
bacteria, opening wide spaces for absorption of 
toxins, trauma, and continuity of tissue. The 
lymphatics rarely transmit infection, which travels 
by the blood stream or by actual continuity as a 
rule. Cocaine was not responsible for any deaths, 
though adrenalin was. Numerous authors are cited 
to show that adrenalin with light chloroform 
anaesthesia is peculiarly dangerous; even with light 
etherization it is thought risky. Deaths due to 
adrenaUn were 4; to haemorrhage, 3; to packing 
nose for epistaxis, i; to puncture, or injection of 
air or fluids into the antrum of Highmore, 10; to 
probing and irrigating frontal sinus, 3; to polyp 
removal, 9; to ethmoid curettement, 4; to turbinate 
operations, 9. 

In the author's personal case, following resection 
of the lower edge of the inferior turbinate of one 
side, the patient never recovered consciousness 
from the ether, and died in three days from cerebro- 
spinal meningitis. It was probably a case of latent 
meningitis before operation. One death was due to 
exploration of the sphenoid sinus; 9 deaths resulted 
from resection of the septum. Deaths from invasion 
of the antrum of Highmore are due to reflex irrita- 
tion of the vagus through the irritation of the second 
branch of the trigeminus which supplies the interior 
of the antrum. It is demonstrable that the interior 
of the nose is a zone of considerable danger for even 
the slightest instrumental interference, and that 
adrenalin combined with a general anaesthetic, 
especially when used for operative assistance, is not 
to be lightly employed. 

Blackburn, W. J.: Submucous Resection of the 
Nasal Septum. J. Ophth., Otol. & Laryngol., 
1916, xxii, 228. 

The universally gratifying results in a series of 
over a hundred operations for submucous resection 
of the septum leads the author to conclude that a 
deviated septum may be the underlying cause of 
many diseases of the nose, throat, and ear. By 
obstructing the nasal respiration, the resistance of 
the tissues of the nose and throat are lowered and 
patients with deviated septa frequently develop 
ethmoiditis, sinusitis, suppurative otitis media, 
mastoiditis with brain abscess, laryngitis, bron- 
chitis, chronic headache, deafness, tinnitus aurium, 
asthma, hay fever, or other neurotic conditions. 

Ellen J. Patterson. 



Sluder, G.: A Galvanocautery Operation for the 
Lower Turbinate. Laryngoscope, 1916, xxvi, 166. 

The pathological condition for which this tech- 
nique is recommended is general swelling (hyper- 
trophy or intumescence) of the soft parts covering 
the lower turbinates; the clinical condition being 
for the most part nasal obstruction with or without 
eustachian tube irritation. 

To the anteroposterior incision usually made in 
cauterization of the inferior turbinate, the author 
has added: (i) a straight one descending in front 
at an angle of 45 degrees from a point a little above 
the line of attachment of the body of the turbinate, 
to meet tangent the anterior limit of the antero- 
posterior incision and then descending below it to 
the level of the free margin of the vestibule, almost 
to the mucocutaneous junction in the vestibule; 
(2) two curved incisions on the body of the turbinate 
posteriorly which are made, operating from the 
postnasal space, by means of a specially curved 
cautery tip introduced through the mouth behind 
the soft palate. One curved incision is made 
above and one below, each beginning i to 1.25 cm. 
in front of the posterior tip and extending backward 
to meet on the lateral wall just at the tip; (3) the 
tip of the cautery is extended forward to a point 
which is to be the posterior end of the anteroposte- 
rior incision and carried backward over the tip to 
the junction of the curved incisions, or even as far 
backward as the cartilage of the anterior lip of the 
mouth of the eustachian tube, especially in those 
cases associated with tubal irritation. 

For all this work the author uses an electrode 
which has no insulation upon it and which con- 
sists of the two copper wires which are united by a 
platino-iridium tip. This permits the wires to be 
separated and spread apart as far as i cm. if desired, 
which transforms the narrow tip into a V- or U- 
shaped end as desired. When this is used on the 
pull any tissue to be removed can be engaged in this 
loop and the current turned on, when it acts like a 
spokeshave. 

The author has a definite order of procedure in 
this work which is as follows: 

After anaesthetizing the turbinate and soft palate 
the latter is forcibly drawn forward by the author's 
self-retaining palate retractor. A large warm post- 
nasal glass is used as a tongue depressor. The 
curved electrode is then introduced cold in a hor- 
izontal plane, through the mouth into the pharynx. 
The glass is then slipped back into the postnasal posi- 
tion, and the tip of the cautery is brought forward 
into the affected nostril, put in place, and the 
current turned on. First the lower curved incision 
is made, next the posterior end of the anteroposte- 
rior incision, and then the upper curved incision. 
This completes the work from the postnasal side. 
From in front the author introduces a straight tip 
to meet the middle posterior incision and carries 
this forward until he reaches the anterior end of the 
incision when he changes the direction of the tip, 
placing it near the anterior tip of the middle tur- 



98 



INTERNATIONAL ABSTRACT OF SURGERY 



binate, when it is drawn downward and forward to 
its prescribed lower limit. The tip used is so hot 
that if it were once removed from the tissue it would 
burn itself out. 

The author has employed this procedure in more 
than 1,000 cases extending over a period of seven- 
teen years. Out of this number 3 cases required 
an anterior packing with Simpson's splints to con- 
trol bleeding. In none of the author's snare and 
scissors' operations has the result been so satisfactory 
as with this method. The author has never seen 
the permanent drying or crusting mentioned by 
some men. This method is also applicable to snar- 
ing off the posterior end of the inferior turbinate. 

Two cases are reported in which deafness, not 
responding to any of the operations for nasal 
obstruction, has responded to this method of 
cauterization especially when the posterior line 
extended to the anterior tip of the pharyngeal 
orifice of the eustachian tube. Otto M. Rott. 

Kellogg, F. B. :^An Improved Submucous Operation. 

/. Ophth., Otol. b° Laryngol., 1916, xxii, 215. 

The author makes his primary incision from high 
up in front of the deviation on the convex side down 
to and half way across the floor. Then elevating 
the membrane above and below the edge of the 
ridge until the mucous membrane of the convex side 
is free except along this edge he inserts the blades of 
a delicate pair of scissors one above and one below 
the ridge and trims off the edge of the ridge leaving 
it attached to the membrane. After elevating the 
membrane on the concave side, he inserts a Bosworth 
saw under the deflection inside the membrane, 
saws off the projecting spur in the plane of the 
septum, removes the spur with forceps, and packs 
with strips of spunk. Ellen J. Patterson. 

THROAT 

Hays, H.: A Simple Tonsil Operation Under Local 
Anaesthesia. Med. Rec, 1916, Ixxix, 419. 

Using Schleich's infiltration anaesthesia, the 
author depresses the tongue firmly and separates the 
tonsil capsule from the anterior pillar working from 
below up with his double-bladed knife. Then using 
his modified aneurism needle threaded with stout 
cord or string, he threads the cord in the deepest 
part of the tonsil from below upward, ties it and 
using the cord as a retractor completes the dissec- 
tion with a Hurd tonsil separator or the index, 
finger. Ellen J. Patterson. 

Shearer, T. L. : The Question of Age in Tonsillec- 
tomy. /. Ophth., Otol. b" Laryngol., 1916, xxii, 205. 

Tonsillectomy is indicated in adults under 40 
years, when the patient has hypertrophied or 
diseased tonsils or the tonsils are the focus of 
infection of pathological conditions remote from the 
tonsil. It is indicated also in malignant disease of 
the tonsil irrespective of age, followed by radium 
radiation of the wound. 



Tonsillectomy is contra-indicated in any adult 
suffering from arteriosclerosis, and adults over 
45 are treated satisfactorily by the electrocautery. 

Ellen J. Patterson. 

Friedberg, S. A.: Removal of Tonsils and Adenoids 
in Diphtheria Carriers. /. Am. M. Ass., 1916, 
Ixvi, 810. 

Several instances have been noted in which the 
local application of kaolin seemed to be without any 
effect on diptheria bacilli. In view of the prompt 
disappearance of the bacilli in these cases after 
tonsillectomy and removal of adenoids, the author 
makes a brief report of the results. 

Six cases are reported, five occurring in children. 
The tonsils were removed after all methods were 
used to rid the throat of diptheria. In two days 
or less the cultures became negative. 

In none of these patients did the operation have 
any different general effects than it has ordinarily. 
In all of the patients the Schick test gave negative 
results just before the operation. Six successive 
negative cultures were required before the patients 
were discharged. 

The results obtained in this series indicate clearly 
that in persistent carriers it may be necessary to 
remove the tonsils and adenoid tissue if it is desired 
to terminate the carrier condition promptly. 

The bacteriologic examination should be made 
with care as it is well known that applications of 
medicinal agents may destroy the bacilli on the 
surface while leaving unaffected those in the crypts 
of the tonsils and the folds of the adenoid tissue. 

As to the time the operation should be performed, 
it is perhaps advisable to wait from two to three 
weeks after the clinical recovery of the patient. 
In the case of the chronic carrier no time limit is 
necessary. Edward L. Cornell. 

MOUTH 

Durante, L.: Tuberculosis of the Tongue. Ann. 
Surg., Phila., 1916, Ixiii, 143. 

In addition to reporting 5 cases of tuberculosis of 
the tongue, the author gives a very complete bibliog- 
raphy of the literature upon this unusual disease. 
He has been able to collect about 250 cases, some of 
which, however, have been recorded without ana- 
tomicoclinical details. The reason for the relative in- 
frequency of the lesions on the tongue, an organ 
which comes in contact with almost all tuberculous 
infecting material, is due, probably, to two factors; 
(i) to the particular structure of the lingual mucosa 
which resists the direct penetration of the bacillus 
tuberculosis; and (2) to the natural resistance which 
all striated muscle presents to the lodgment of the 
bacilli. Almost all of the cases cited occurred be- 
tween the twentieth and fiftieth year, and no case 
has been recorded as occurring in infancy, the age 
in which tuberculous lesions are so common and 
widespread. From these considerations, the author 
concludes that the tuberculous process in the tongue 



SURGERY OF THE NOSE, THROAT, AND MOUTH 



99 



is assisted by such lesions as trauma of the mucosa 
by pipe stems, by carious teeth, by toxic glossitis, 
etc., and that as these causes are more frequent in 
men than in women, lingual tuberculosis is to be 
expected more frequently in men. Statistics bear 
out this contention, as Chvostek reports one woman 
to every four men and Delavan records one in 
twenty-three. 

While theoretically tuberculosis may be localized 
in the tongue by the blood-vessels, by the lymphatics, 
by direct infection, or by extension from surround- 
ing organs, practically it is impossible to determine 
the exact method of infection. Many of the cases 
reported in the literature as "primary" tuberculosis 
were not controlled by autopsy so that the term must 
be accepted in the clinical sense only. The theo- 
retical possibility of a primary tuberculosis of the 
tongue is practically confirmed by two cases which 
the author collected in which the patients died from 
other causes and careful post-mortem examinations 
gave no evidence of tuberculous infection in other 
organs. In the majority of cases, the localization 
was secondary to a tuberculous process elsewhere in 
the body. From the histologic examination of the 
tissue removed from the five patients reported by 
the author and from the statistics collected by him, 
the indications all seem to point to a haematogenous 
infection as the most common method of infection 
of the tongue by tuberculosis. 

The anatomical forms of the disease do not rep- 
resent a distinct anatomical entity, but diverse 
forms of the same evolutionary process, depending 
upon the virulence of the bacilli, the local resistance 
of the tissues, and the systemic resistance of the 
patient, are found in various cases and in various 
parts of the tongue in the same case. The begin- 
ning is always characterized by new formation of 
tuberculous nodules which may be localized sepa- 
rately in the dermis of the mucosa or in the lingual 
parenchyma. From this initial localization of the 
tuberculous process, two clinically different types 
may originate. The first presents itself initially 
as a plaque of gray color, somewhat elevated above 
the surrounding mucosa, hard to the touch, and 
without inflammatory reaction. It resembles 
cutaneous lupus, and is very often accompanied 
by lupous lesions of the buccal mucosa, of the nose, 
or of the skin of the face. This type is referred to as 
glossodermatitis tuberculofibrosa, or, should it 
ulcerate, as glossodermatitis tuberculo-ulcerosa. 
When, on the other hand, the parenchyma of the 



tongue is primarily affected nodular tuberculosis 
may result or the lesions may become confluent or 
disseminated in various regions — disseminated 
miliary tuberculosis of the tongue. The second type 
in any of its various forms may maintain its ana- 
tomic individuality for months or years simulating 
either a neoplastic lesion or the localization of 
tertiary lues. The typical tuberculous ulcer has 
irregular margins, sinuous, soft, and reddened, with 
a soft yellow base. It may appear in any region 
of the tongue, but with more frequency on the 
margins and the tip. The adenitis which accom- 
panies it is often bilateral and slightly painful to 
pressure. Usually there is not much difficulty in 
finding the bacillus in tuberculous glossitis, although 
undoubted cases have been reported without the 
bacillus being found. 

The symptoms vary considerably with the stage 
of evolution of the disease. The initial period is 
marked with few or no subjective symptoms. When 
the ulcerative form develops, there is abundant 
salivation and some pain due mostly to the passage 
of food. The pain may limit the mobility of the 
tongue. In the ulcerative type which is complicated 
by secondary infection there is usually painful 
regional adenopathy, but in the closed form of 
lingual tuberculosis it is often absent. 

Diagnosis in the early stage of the process pre- 
sents great difficulty. Mistaken for epitheliomatous 
neoplasms, amputations of the tongue with radical 
removal of the glands of the neck have been done 
for tuberculous glossitis. Mercurial treatment has 
been employed in i8o reported cases, showing the 
freqeuncy with which it has been mistaken for 
tertiary lues. There are no sure criteria of differen- 
tiation, and it is always well in case of doubt to 
employ the microscopic examination of the tissue 
of the lesion. This can usually be done by frozen 
sections during the operation, as was done in each 
of the cases reported by the author. 

The prognosis is favorable when the tuberculosis 
of the tongue presents itself as a primary and unique 
lesion. It is generally unfavorable when the lingual 
lesion is a late localization secondary to a broncho- 
pulmonary process. 

The treatment of election, which has been avoided 
by previous authors, has been operative when the 
tuberculous lesion of the tongue was single and 
circumscribed. In the multiple and diffuse lesions, 
the treatment recommended has been local with the 
cautery. Gatewood. 



BIBLIOGRAPHY OF CURRENT LITERATURE 



GENERAL SURGERY 



SURGICAL TECHNIQUE 



Note. — The bold face figures in brackets at the right of a reference indicate the page of this issue on which an 
abstract of the article referred to may be found. 



Operative Surgery and Technique 

Wound dressings. D. H. Stewart. Med. Press & 
Circ, 1916, ci, 286. 

Wound dressings. H. S. Stewart. Am. J. Obst., 
N. Y., 1916, Ixxiii, 284. 

The physics of a surgical dressing, with special reference 
to the harmful effect of using impermeable material over 
septic wounds. A. Primrose. Brit. M. J., 1916, i, 238. 

[17] 

Non-adhering surgical gauze. H. E. Fisher. J. Am. 
M. Ass., 1916, Ixvi, 939. [17] 

Use of fluoroscope to avoid leaving gauze pads and 
sponges in the abdomen. E. O. Kane. Am. Med., 1916, 

xi, 55- 

Papillomatous growths in old operation scar. J. L. 
Bunch. Proc. Roy. Soc. Med., 1916, ix, Sect. Dis. Child., 
28. 

Acute dilatation of the stomach complicating operations 
on the extremities. I. Cohn. Ann. Surg., Phila., 1916, 
Ixiii, 263. 

A stitch to assist in the closure of the posterior sheath of 
the rectus above Douglas' semilunar fold. N. W. Green. 
Ann. Surg., Phila., 1916, Ixiii, 364. 

After laparotomy. E. Forque. Ann. de gynec. et 
d'obst.. Par., 1916, xlii, 79. 

Aseptic and Antiseptic Surgery 

Toluol as a storing fluid for catgut. A. Rogers. Ann. 
Surg., Phila., 1916, Ixiii, 312. 

The surgical and antiseptic values of hypochlorous acid 
(eusol). J. Eraser and H. J. Bates. Edinb. M. J., 
1916, xvi, 172. [17] 

Clinical report on the application of eusol; report to the 
Medical Research Committee. Lancet, Lond., 1916, cxc, 

356- ... . . . .[18] 

Systematic iodine treatment in the important infections. 

L. Boudreau. J. de med. de Bordeaux, 1915, Ixxvii, 39. 
Cure of septic wounds by abstention. L. Isnardi. 

Gior. d. r. Accad. di med. di Torino, i9i5,lxxviii, 451. 

Anesthetics 

Practical anaesthesia, showing a new ether apparatus. 
B. Morgan. Lancet-Clin., 1916, cxv, 230. 

The use of warmed ether vapor for anaesthesia. F. B. 
McCarty and B. F. Davis. Ann. Surg., Phila., 1916, 
Ixiii, 305. 

The choice of anaesthetic in war surgery. I. Regnault. 
Rev. gen. de clin. et de therap., 1916, xxx, 217. 

Prolonged ethyl chloride anaesthesia during extensive 
dressings. Savariaud. Presse med., 1916, p. 45. 



General anaesthesia by ethyl chloride in war surgery. 
J. Carles and A. Charrier. J. de med. de Bordeaux, 
1916, Ixxvii, 49. 

Sudden death in chloroform narcosis. H. E. Hering. 
Muenchen. med. Wchnschr., 1916, Ixiii, 521. 

Some observations on anaesthesia and analgesia. D. E. 
Jackson. J. Pharmacol. & Exp. Therap., 1916, viii, 113. 

[18] 

An apparatus for the administration of gas-oxygen. 
W. Walter. N. Y. M. J., 1916, ciii, 352. [18] 

Notes on nitrous oxide administration. R. C. Coburn. 
J. Am. M. Ass., 1916, Ixvi, 799. 

The advantages and risks of combined local and general 
anaesthesia. W. H. B. Aikins. Canad. Pract. & Rev., 
1916, xli, 96. [19] 

Spinal anaesthesia. G. Hanes. Louisville Month. J., 
1916, xxii, 289. [19] 

Caudal anaesthesia in genito-urinary surgery. B . Lewis 
and L. Bartels. Surg., Gynec. & Obst., 1916, xxii, 262. 

[19] 

Deaths caused by intraspinal novocaine analgesia. 
H. J. BoLDT. Am. J. Obst., N. Y., 1916, Ixxiii, 485. 

Practical notes on local anaesthesia in otorhinology. 
G. Mahn. Ann. d. mal. de I'oreille et du larynx, Par., 
1916, xl, 845. 

The inhibition of the toxicity of anaesthetics for the 
nephropathic kidney. W. D. MacNider. J. Pharmacol. 
& Exp. Therap., 1916, viii, 116. 

Surgical Instruments and Apparatus 

A new and convenient instrument sterilizer. J. Mac- 
Donald, Jr. Am. J. Surg., 1916, xxx, 94. 

Concerning rubber gloves. R. T. Morris. Med. Rec, 
1916, Ixxxix, 413. 

Damp bandages without the use of waterproof material. 
Schaefer. Muenchen. med. Wchnschr., 1916, p. 227. 

Salicyl-sugar bandages. O. Herff. Muenchen. med. 
Wchnschr., 1916, p. 227. 

A new spiral drainage tube. H. De L. Crawford. 
Lancet, Lond., 1916, cxc, 680. 

Pillar-compression forceps for controlling haemorrhage 
following tonsillectomy. J. Z. Bergeron. J. Am. M. 
Ass., 1916, Ixvi, 505. [20] 

Prosthetic apparatus for muscles in paralysis of the limb 
nerves. B. Cuneo. Bull, et mem. Soc. de chir. de Par., 
1916, xlii, 589. 

Immobilizing apparatus for open fractures and for artic- 
ulation injuries. Levy. Presse med., 1916, p. 133. 

Bandage material for frost-bite cases. Spieler. Wien. 
klin. Wchnschr., 1916, No. 4. 

A bandage for the lower extremities kept in position by 
a weight. Kertesz. Wien. kUn. Wchnschr., 1916, No. 3. 



100 



BIBLIOGRAPHY OF CURRENT LITERATURE 



lOI 



SURGERY OF THE HEAD AND NECK 



Head 

Gunshot injuries of the head. Uffenorde. Berl. 
klin. Wchnschr., 1916, xxv, 380. 

Gunshot injuries of the head. Koenig. Muenchen. 
med. Wchnschr., 19 16, Ixiii, 500. 

Observ^ations on gunshot wounds of the head. H. M. 
W.Gray. Brit.M. J., i9i6,i, 261. [20] 

The immediate treatment of head injuries from pro- 
jectiles. A. Schwartz and P. Mocquot. Practitioner, 
Lond., 1916, xcvi, 278. 

Severe wound of the face by shell; reparatory operation. 
H. MoRESTiN. Bull, et m6m. Soc. de chir. de Par., 1916, 
xlii, 858. 

The treatment of wounds of the face and jaws sustained 
in war. M. Roy and P. Martestier. Ann. di odont., 
Roma, 1916, i, 185. 

Piece of shell entering by right cheek, having broken the 
lower maxillary, traversed the mouth and pharyngeal 
walls and injured the third and fourth cervical vertebrae. 
C. Walther. Bull, et mem. Soc. de chir. de Par., 1916, 
xlii, 866. 

The care of nose injuries. E. Schlesinger. Muenchen. 
med. Wchnschr., 1916, p. 225. 

Bone transplantation in nose deformiries. F. S. Cook. 
Wis. M. J., 1916, xiv, 427. [21] 

The technique of preparing artificial noses. Zinsser. 
Muenchen. med. Wchnschr., 1916, p. 223. 

Plastic substitutes for lost nose tip from the skin of the 
bridge of the nose. Lesser. Muenchen. med. Wchnschr., 
1916, p. 225. 

Destruction of root of nose; plastic operation and car- 
tilaginous graft. H. MoRESTiN. BuU. et m6m. Soc. de 
chir. de Par., 1916, xlii, 862. 

Bad condition of the mouth as a cause of appendicitis, 
cancer, and other diseases. A. Patino. Odont. Colomb., 
Bogota, 1915, vi, 113. 

Infections of the mouth, ear, nose, and throat as primary 
foci for secondary infections. D. B. Parker. Long 
Island M. J., 1916, x, 97. 

Wound of the face and of the maxUlary pharyngeal space 
by a voluminous projectile. H. Morestin. Bull, et 
mem. Soc. de chir. de Par., 1916, xlii, 673. 

Calculi in the submaxillary gland and Wharton's duct. 
F. S. Mathews. Ann. Surg., Phila., 1916, Ixiii, 140. 

[21] 

Primary tuberculosis of the lower jaw. I. Zilz. 
Oesterr. Ztschr. f. Stomatol., 1916, xiv, 22. 

War injuries of the jaws and face. J. L. Payne. 
Lancet, Lond., 1916, cxc, 569. 

Extensive resection of the lower maxillary; immediate 
prosthesis. E. Qu£nu. Bull, et mem. Soc. de chir. de 
Par., 1916, xlii, 814. 

Congenital cysts of the upper maxilla. D. Massa. 
Rev. dental, Santiago di Chile, 1915, viii, 225. 

Treatment of maxillary fractures. V. H. Kazanjian. 
Brit. M. J., 1916, i, 266. [21] 

The treatment of gunshot injuries of the jaw. R. 
Weiser. Oesterr. Ztschr. f. Stomatol., 1916, xiv, i. 

Deformities of the jaws resulting from operation or in- 
jury. P. P. Cole and C. H. Bubb. Brit. M. J., 1916, i, 
268. [21] 

Surgery of the maxillae. A. Cabrera. Rev. dental, 
Santiago di Chile, 1916, ix, 97. 

The treatment of parotid tumors by radium. R. Weil. 
J. Am. M. Ass., 1915, Ixv, 2138. [22] 



Complete removal of parotid gland without injury to 
facial nerve. J. H. Barbat. Calif. St. J. Med., 1916, xiv, 

"5: 

Sinus thrombosis in compression. C. E. Reynolds. 
J. Am. M. Ass., 1916, Ixvi, 952. 

Removal of intracranial foreign body under X-rays. 
J. R. Lee. Brit. M. J., 1916, i, 447. 

Radiography in gunshot woimds of the skull. G. 
ViLVANDRf. Arch. Radiol. & Electrotherap., 1916, xx, 
306. 

Cranial injuries. O. Klieneberger. Deutsche med. 
Wchnschr., 1916, xlii, 309. 

Wounds of the cranium by firearms. Mainonnet. 
Presse med., 1916, p. 133. 

Two cases of penetrating wounds of the skull by pro- 
jectiles. TissoT. BuU. et mem. Soc. de chir. de Par., 
1916, xlii, 625. 

Research for homolateral symptoms in cranial and 
encephalic perforations by projectiles. Duperi£. Presse 
med., 1916, p. 174. 

Eighty cases of cranial vault injuries by war projectiles. 
Debache. Bull, et m6m. Soc. de chir. de Par., 1916, xlii, 
625. 

Endothelioma of left frontal lobe. C. F. Nassau and 
G. E. Price. Ann. Surg., Phila., 1916, Ixiii, 380. 

Repair of losses of frontal substance by means of car- 
tilaginous transplants. H. Morestin. Bull, et mem. 
Soc. de chir. de Par., 1916, xlii, 424. [22] 

Hemianopsia by cranial contusion. V. Morax. Ann. 
d'ocul., 1916, cliii, 112. 

Intracranial haemorrhage due to traumatic rupture of 
arteria meningea media; report of six operated cases with 
one death. L. H. L.\nt)ry. South. M. J., 1916, ix, 157. 

[22] 

Intracranial aerocele. E. H. Skinner, j. Am. M. 
Ass., 1916, Ixvi, 954. 

Septic intracranial thrombosis accompanied by frontal 
sinusitis followed by abscess of the brain. A. Gordon. 
Virg. M. Semi-Month., 1916, xx, 575. 

Cranial tumor (dermoid by implantation). W. L. 
Christie. Brit. M. J., 1916, i, 416. 

Delayed trepanation. Le Fort. Presse med., 1916, 

P- 174- 

Operative technique in woimds of the cranium. Rocher. 
Presse med., 1916, p. 133. 

Operative indications in wounds of the cranium . PiCQu£ 
Presse med., 1916, p. 133. 

Extraction of a piece of shell in the posterior part of 
the right lateral mass of the ethmoid. C. Walther. 
Bull, et m^m. Soc. de chir. de Par., 1916, xlii, 823. 

Cartilaginous graft in a cranial defect. L. Bazy. Bull, 
et mem. Soc. de chir. de Par., 1916, xlii, 676. 

Cranioplasty by cartilaginous flap. A. Gosset. Bull, 
et mem. Soc. de chir. de Par., 1916, xlii, 444. [22] 

Meningo-ependymitis and its treatment by trepano- 
puncture. F. Ramond. Bull, et m6m. Soc. de h6p. de 
Par., 1916, xl, 351. 

Types of hydrocephalus — their differentiation and 
treatment. C. H. Frazler. Am. J. Dis. Child., 1916, 
xi,9S. [23] 

The relation of the pathological bases of hydrocephalus 
to its surgical alleviation. C. M. Remsen. Interst. M. 
J., 1916, xxiii, 89. [23] 

Congenital encephalocele; excision; consecutive hydro- 
cephalitis. Planchu and Novi;-JossER.\ND. Ann. de 
gyn^c. et d'obst., Par., 1916, xlii, 117. 



I02 



INTERNATIONAL ABSTRACT OF SURGERY 



Glioma of the cerebellum with metastases. F. M. 
Jacob. J. Med. Research, 1916, xxxiv, 95. [24] 

Penetrating wound of the parieto-occipital region; 
cerebral abscess; operation; recovery. Rottenstein and 
Raulin. Bull, et mem. Soc. de chir. de Par., 1916, xlii, 
625. 

A rare case of cerebellar abscess. B. Haseltine. J. 
Ophth., Otol. & Laryngol., 1915, xxi, 650. 

Cerebral abscess, probably primarily due to suppurative 
tonsilitis. T.B.Throckmorton. Chicago M. Recorder, 
1916, xxxviii, 128. 

Cerebellar tumor. J. L. Campbell. J.-Rec. Med., 
1916, Ixii, 539. 

Studies on the localization of cerebellar tumors. 

E. G. Grey. Ann. Surg., Phila., 1916, Ixiii, 129. 

[24] 
The pituitary fossa and the surgical methods of ap- 
proach to it. V. Z. Cope. Lancet, Lond., 1916, cxc, 
601. 

The influence of pituitary feeding upon growth and 
sexual development. E. Goetsch. Bull. Johns Hop- 
kins Hosp., 1916, xxvii, 29. 

Neck 

Lymphadenoma of the neck. L. Razetti. Gac. 
med. de Caracas, 1916, xxiii, 26. 

Tracheobronchial tuberculous adenopathy; its relation 
to the lymphoid organs of the neck. Presta. Arch, de 
ginec, obst. y pediat., 1916, xxix, 69. 

The non-surgical treatment of tuberculous glands. A. 

F. Holding. Med. Rec, 1916, Ixxxix, 471. 

Tumors of the carotid body. R. Winslow. Tr. Am. 
Surg. Ass., Washington, 1916, May. [25] 

Resection in the case of projectile wounds of the neck. 
Leriche. Bull, et mem. Soc. de chir. de Par., 1916, xlii, 
416. [26] 



Cervical ribs; report of seven cases with one operative 
case. W. W. Plummer. Am. J. Orth. Surg., 1916, xiv, 
146. 

Wound of the subhyoid region; lesion of the two hypo- 
glossal nerves. C. Walther. Bull, et m6m. Soc. de 
chir. de Par., 1916, xlii, 646. 

Prolonged use of tubes following diphtheria. A. J. 
Bell. Arch. Pediatrics, 1916, xxxiii, 161. 

Rare complications of a diphtheric tracheal and laryngeal 
stenosis. T. Cohnen. Deutsche med. Wchnschr., 1916, 
xlii, 323. 

The function of the thyroid-parathyroid apparatus. 
E. C. Kendall. J. Am. M. Ass., 1916, Ixvi, 811. 

Hj^ofunction of the thyroid in relation to arterioven- 
tricular automatism of the heart. S. Sakai. Mitt. a. 
d. med. Fak. d. K. Univ. Tokyo, 1915, xv, 103. 

Tonsillar endamoebiasis and thyroid disturbances. J. 
S. Evans, W. S. Middleton, and A. J. Smith. Am. J. 
M. Sc, 1916, cli, 210. [26] 

Surgery of the thyroid. V. Knott. J.-Lancet, 1916, 
xxxvi, 138. 

Observations on the blood-pressure in cases of dys- 
thyroidism. J. M. Swan. Interst. M. J., 1916, xxiii, 
186. 

Goiter. J. K. Corss. Virg. M. Semi-Month., 1916, 
XX, 591. 

A brief resume of the goiter question. J. D. Elliott. 
Hahneman. Month., 1916, li, 170. 

Exophthalmic goiter; accessory thyroid. W. F. Camp- 
bell. Med. Times, 1916, xliv, 88. 

The cerebral nerve disturbances in exophthalmic 
goiter. G. J. Reder. Am. J. M. Sc, 1916, cli, 

339- 

The physiology of the parathyroid glands. W. F. 
Koch. J. Lab. & Clin. Med., 1916, i, 299. [26] 

What goiters demand operation? F. H. Lahey. Bos- 
ton M. & S. J., 1916, clxxiv, 273. 



SURGERY OF THE CHEST 



Chest Wall and Breast 

Cancer of the breast. C. G. Viehe. Lancet-Clin., 
1916, cxv, 273. 

Hypophyseal disorder in mammary cancer and its re- 
lation to diabetes insipidus. S. Sekiguchi. Ann. Surg., 
Phila., 1916, Ixiii, 297. 

Mammary, carcinoma; report of two atypical cases. 
C. C. Mapes. Internat. J. Surg., 1916, xxix, 75. 

Wounds of the chest. H. Bouquet. Bull. gen. de 
therap., 1916, clxviii, 749. 

Penetrating wounds of the chest in warfare. H. 
Perreau. Med. Press & Circ, 1916, ci, 100. [27] 

The medical aspects of chest injuries. R. M. Leslie. 
Practitioner, Lond., 1916, xcvi, 301. 

Fracture of the first right rib. T. P. Codd. Med. 
Press & Circ, 1916, ci, 196. 

Gunshot wounds of the thorax. W. M. Boothby. 
Boston M. & S. J., 1916, clxxiv, 378. [28] 

Treatment of spontaneous pneumothorax. A. Pisani. 
Gazz. d. osp. e d. clin., Milano, 1916, xxxvii, 370. 

Treatment of empyema of the breast of dental origin. 
A. E. Larrauri. Rev. dental, Santiago di Chile, 1915, 
viii, 260. 

Enlarged thymus in infancy. J. F. Herrick. Surg., 
Gynec. & Obst., 1916, xxii, ^;^;^. [29] 



Trachea and Lungs 

Foetid abscess of the lung cured in twelve days by fili- 
form metallic drainage without costal resection. Chaput 
and Galliard. Bull, et mem. Soc. de chir. de Par., 1916, 
xlii, 855. 

Roentgenographic diagnosis of pulmonary tubercu- 
losis. K. Dunham. Am. J. Roentgenol., 1916, iii, 

Radiographic diagnosis of metastatic pulmonary malig- 
nancy. A. B. Moore and R. D. Carman. Am. J. 
Roentgenol., 1916, iii, 126. 

The surgical extraction of intrapulmonary projectiles, 
superficial and deep, under the screen, by simple, rapid, and 
certain means. P. de la Villeon. Bull. Acad, de med., 
Par., 1916, Ixxv, 275. [30] 

Tumor of the left shoulder blade with metastases in the 
right lung. Silbergleit. Deutsche med. Wchnschr., 
1916, xlii, 435. 

Lung fistula. Forster. Berl. klin. Wchnschr., 1916, 
XXXV, 380. 

Carnage caused by a fraction of shell in the lung. C. 
Walther. Bull, et mem. Soc. de chir. de Par., 1916, 
xlii, 912. 

Some experiments in lung surgery. C. Georg, Jr. 
J. Mich. St. M. Soc, 1916, xv, 135. 



BIBLIOGRAPHY OF CURRENT LITERATURE 



103 



Heart and Vascular System 

Wound of the heart. Fourmestraux and Ledoux. 
Progres med., 1916, p. 48. 

Concerning a case of projectile in the heart. G. 
SiLVAR. Gazz. d. osp. e d. cUn., Milano, 1916, xxxvii, 

333- 

Heart showing infiltration by a large round-celled 
sarcoma. E. C. Williams. Proc. Roy. Soc. Med., 1916, 
ix, Sect. Dis. Child., 36. 



Projectile remaining in the wall of heart. Fuhrmann 
and B. Kautsky. Berl. klin. Wchnschr., 1916, xxxv, 382. 

Pharynx and CEsophagus 

Foreign body in the oesophagus. Thost. Deutsche 
med. Wchnschr., 1916, xlii, 337. 

Congenital atresia of the oesophagus; report of a case. 
E. O. Jones and J. B. Manning. J. Am. M. Ass., 1916, 
Ixvi, 810. 



SURGERY OF THE ABDOMEN 



Abdominal Wall and Peritoneum 

A tabular statement of 500 abdominal gunshot injuries. 
C. Wallace. Lancet, Lond., 1916, cxc, 502. [30] 

Some considerations on abdominal wovmds and their 
treatment. J. Huertas. Rep. de med. y dr., Bogota, 
1916, vii, 256. 

Cystic tiunors of the abdomen with report of three cases. 
W. A. HoYT. J. Mich. St. M. Soc, 1916, xv, 129. 

Treatment of abdominal gunshot injuries. Wilmanns. 
Deutsche med. Wchnschr., 1916, xlii, 410. 

Treatment of penetrating abdominal wounds in am- 
bulances. A. Schwartz and P. Mocquot. Rev. de chir., 
Par., 1916, xxxv, 56. 

Peritoneal adhesions; their prevention with citrate 
solutions. M. H. Walker, Jr. and L. M. Ferguson. 
Ann. Surg., Phila., 1916, Ixiii, 198. [31] 

The prevention of, peritoneal adhesions by the use of 
citrate solution. S. Pope. Ann. Surg., Phila., 1916, 
Ixiii, 205. [32] 

A case of chronic non-tuberculous peritonitis in a child. 
C. Worster-Drought. Brit. M. J., 1916, i, 449. 

Venoperitoneostomy for ascites. C. Goodman. Med. 
Rec, 1916, Ixxxix, 493. 

Eventration of the diaphragm, with report of a case of 
right-sided eventration. S. Bayne-Jones. Arch. Int. 
Med., 1916, xvii, 221. [32] 

The end-results in seventy consecutive cases of umbilical 
hernia operated upon at the Massachusetts General Hos- 
pital. C. C. Simmons. Boston M. & S. J., 1916, cLxxiv, 

342. 

Strangulated hernia with operation described and 
illustrated. L. C. Fisher. Atlanta J.-Rec. Med., 1916, 
Ixii, 569. 

A unique case of post-operative ventral hernia without 
the usual hernia coverings. R.Hill. J. Mo. St. M. Ass., 
1916, xiii, 127. 

Mesocolic or retrogastric hernia. L. Urrutia. Se- 
maine m6d., 1916, xxiii, 216. 

Lumbar hernia. J. Speese and E. H. Goodman. Ann. 
Surg., Phila., 1916, Ixiii, 377. 

Treatment of large crural hernias by adipose pediculated 
graft. Chaput. Rev. de gynec. et de chir. abdom., 1916, 
xxiii, 431. 

The r61e of the superior mesenteric vessels in abdominal 
disease. J. N. Hall. N. Y. St. J. Med., 1916, xvi, 135. 

An unusual case of mesenteric transplantation. V. 
■ Castro. J. Am. M. Ass., 1916, Ixvi, 734. 



Gastro-Intestinal Tract 

Diagnosis of stomach diseases. Litchtwitz. 
klin. Wchnschr., 1916, xxxv, 380. 



Beri. 



The use of the X-ray as an aid in surgical opera- 
tions. L. R. Fairhill. Calif. St. J. Med., 1915, xiii, 
479-. 

Aids in the diagnosis of surgical conditions of the 
stomach with especial reference to the characteristic X-ray 
appearance of the syphilitic hour-glass in contrast to those 
of simple ulcer and cancer. J. W. Dewis. Canad. M. 
Ass. J., 19x5, V, 1056. [32] 

Roentgen ray diagnosis of gastric lesions. J. W. 
Squires. N. Y. M. J., 1915, cii, 1227. [33] 

The differential diagnosis of lesions of the stomach and 
duodenum. E. H. Beckman. Lancet-Clin., 1916, cxv, 
242. 

The significance of certain roentgenographic findings in 
the gastro-intestinal tract. C. L. Palmer. J. Am. M. 
Ass., 1916, Ixvi, 493. [33] 

Infections of the mouth, nose, and throat as primary foci 
for infections in the gastro-intestinal tract. A. F. R. 
Andresen. Long Island M. J., 1916, x, 102. 

Perforating gastric ulcer. E. W. Peterson. Proctol. 
& Gastroenterol., 1916, x, 17. 

A few points concerning gastric ulcer. E. D. Holland. 
Lancet-Clin., 1916, cxv, 263. 

A study of the gastric ulcers following removal of the 
adrenals. F. C. Mann. J. Exp. Med., 1916, xxiii, 203. 

[33] 

Chronic gastric and duodenal ulcer. W. H. Bradford. 
J. Maine M. Ass., 1916, vi, 232. 

A consideration of gastric and duodenal ulcer from the 
standpoint of the internist. W. F. Boggess. Lancet- 
Clin., 1916, cxv, 199. 

The treatment of gastric ulcer, with especial reference to 
its etiology as an infective process. F. R. Andresen. 
Med. Rec, 19 16, Ixxxix, 457. 

The etiologic relationship existing between gastric ulcer 
and gastric cancer; an analysis of 921 cases of gastric can- 
cer and 500 cases of gastric ulcer. F. Smithies. Lan- 
cet-Clin., 1916, cxA', 203. 

Three cases of abdominal growths presenting very 
unusual characters. C. A. Morton. Brit. M. J., 1916, 

1,413- 

A color reaction in the urine test in cancer of stomach. 
F. Blumenthal. Muenchen. med. Wchnschr., 1916, 
Ixiii, 530. 

Carcinoma of the stomach. Judd. Proctol. & Gas- 
troenterol., 1916, X, 19. 

The modern method of treatment of diseases of the 
stomach. J. Friedenwald. Therap. Gaz., 1916, xl, 
77. , , [34] 

Recent observations in stomach surgery. R. T. Fer- 
guson. J. So. Car. M. Ass., 1916, xii, 83. 

Total ablation of gastric mucosa. P. Dell a Torre. 
Clin, chir., Milano, 1916, No. i, 29. 



I04 



INTERNATIONAL ABSTRACT OF SURGERY 



Pupillary dilatation in gastric pathology. G. Leven. 
Bull, gen de therap., 1916, clxviii, 762. 

Surgery in the infant; report of a case. J. W. Henson. 
Virg. M. Semi-Month., 1916, xx, 590. 

Roentgen studies after gastric and intestinal operations. 
J. T. Case. J. Am. M. Ass., 1915, Ixv, 1628. [34] 

Gastro-enterostomy and occlusion of the pylorus by 
means of a heavy Pagenstecher thread. W. A. Downes. 
Proctol. & Gastroenterol., 1916, x, 19. 

Operative treatment of pyloric obstruction in infants; 
review of sixty-six personal cases. W. A. Downes. 
Surg., Gynec. & Obst., 1916, xxii, 251. [34] 

Ulcer of the duodenopyloric fornix. G. Jefferson. 
Ann. Surg., Phila., 1916, Ixiii, 328. [35] 

Perforated duodenal ulcer. E. W. Peterson. Proc- 
tol. & Gastroenterol., 1916, x, 18. 

Duodenal ulcer. A. Bassler. N. Y. M. J., 1916, ciii, 
582. 

Duodenal and jejunal ulcers. G. G. Gillon. Brit. 
M. J., 1916,1,343. 

Ulcers new and old; jejunal for duodenal ulcers. J. 
Bland-Sutton. Brit. M. J., 1916, i, 272. 

The anatomical and physiological subdivisions of the 
duodenum, with a note upon the pathogenesis of ulcer. 
G. Jefferson and G. Flumerfelt. Ann. Surg., Phila., 
1916, Ixiii, 318. 

Some diseases of the duodenum and complications in- 
volving the surrounding parts. N. I. Stebbins. J. Mo. 
St. M. Ass., 1916, xiii, 116. 

Successful closure of a duodenal fistula persisting after 
a stomach resection. O. Rothschild. Muenchen. med. 
Wchnschr., 1916, Ixiii, 490. 

Faecal fistula of the abdomen. R. Parker. Med. 
Press & Circ, 1916, ci, 257. 

Strangulation of the small intestine in prolapse of the 
large intestine above an anus contra-natura. Guibe. 
Rev. de chir., Par., 1916, xxxv, 138. 

Treatment of intestinal occlusion. Hartmann. Rev. 
gen. de clin. et de therap., 1916, xxx, 343. 

Intussusception of the small intestine due to fibromyo- 
ma; excision; recovery. R. P. Rowlands. Brit. M. J., 

1916,1,343- 

Symptomatology of congenital intestinal obstructions. 
F. Van der Bogert. Arch. Pediatrics, 1916, xxxiii, 
194. 

Ulcer of the jejunum. R. C. Bryan. Surg., Gynec. 
& Obst., 1916, xxii, 279. [35] 

Iliocaecal invagination; operation; cure. G. Egidi. 
Policlin., Roma, 1916, No. 13. 403. 

The roentgen examination of the appendix. M. J. 
Hubeny. Illinois M. J., 1916, xxix, 109. 

The relation of the caeca and appendices of vertebrates 
to diet. D. D. Deneen. Lancet-Clin., 1916, cxv, 279. 

Cystic dilatation of the vermiform appendix. G. E. 
Dodge. Ann. Surg., Phila., 1916, Ixiii, 334. 

Fibroid degeneration of the appendix. R. T. Morris. 
J. M. Soc. N. J., 1916, xiii, 120. 

Appendicitis. I. Hardy. W. Virg. M. J., 1916,' x, 

303- 

Can we diagnose appendicitis? P. I. Nixon. Med. 
Rec, 1916, Ixxxix, 469. 

A contribution to the diagnosis of appendicitis in child- 
hood. F. L. Wachenheim. Arch. Pediatrics, 1916, 
xxxiii, 197. 

The etiology of appendicitis. C. Chase. Am. J. 
Obst., N. Y., 1916, Ixxiii, 444. 

Acute appendicitis. J. B. Deaver. N. Y. M. J., 1916, 
ciii, 241. [35] 

Chronic appendicitis; aneurism of abdominal aorta. 
C. B. Spalding. Pediatrics, 1916, xxviii, 95. 



Appendicitis with the caecum on the left side. G. W. 
Christie. Lancet, Lond., 1916, cxc, 676. 

Gelatinous carcinoma of the large intestine. W. Latz- 
KO. Gynaek. Rundschau, 1916, x, 70. 

Constipation — the cause of nearly all rectal diseases. 
W. J. Murphy. Am. Med., 1916, xi, 173. 

Morphography of two hundred and eighty-five colons. 
J. E. Davis. Am. J. Obst., N. Y., 1916, Ixxiii, 474. 

A study of the ascending colon. J. M. Bell. Med. 
Herald, 1916, xxxv, 83. 

Congenital dilatation of the colon. R. M. Smith. 
Lancet-Clin., 1916, cxv, 269. 

Polyposis of the colon. H. W. Soper. Am. J. M. Sc, 
1916, cli, 405. 

Epiploon and pericolitis. P. Descomps. Rev. de chir., 
Par., 1916, xxxv, 109. 

Megacolon. J. C. Hubbard. Ann. Surg., Phila., 1916, 
Ixiii, 349. 

Sigmoidovesical fistula. R. C. Bryan. Ann. Surg., 
Phila., 1916, Ixiii, 353. 

Diseases of the rectum. H. E. Dunne. Maryland 
M. J., 1916, lix, 53. 

Wounds of the rectum. Couteaud. Bull, et mem. 
Soc. de chir. de Par., 1916, xiii, 596. 

Stricture of the rectum. Protherat. Progres m6d., 
1916, p. 42. 

Rupture of the sigmoid by inflation through the rec- 
tum. A. D. Whiting. Ann. Surg., Phila., 1916, Ixiii, 
376. 

Rectal fistulae. M. L. Bodkin. Med. Times, 1916, 
xliv, 77. 

Fistula of the rectum. C. J. Drueck. Proctol. & 
Gastro-enterol., 1916, x, 7. 

The radical operation for cancer of the rectum and recto- 
sigmoid. W. J. Mayo. Tr. Am. Surg., Ass., Washing- 
ton, 1916, May. . [36] 

Complete removal of the intestinum rectum et colon 
pelvinum for carcinoma. H. J. Hoeve. Internat. J. 
Surg., 1916, xxix, 35, 79. 

Imperforate anus and other congenital deformities. 
B. Bernstein. South African M. Rec, 1916, xiv, 72. 

Fistula-in-ano in a child. S. L. Bacellato. South. 
M. J., 1916, ix, 260. 

Internal haemorrhoids. C. J. Drueck. Am. Med., 
1916, xi, 166. 

The treatment of haemorrhoids by injection. A. S. 
MoRLEY. Lancet, Lond., 1916, cxc, 617. 

A new hemorrhoidal operation; the snare and bullet. 
W. F. Burrows and E. C. Burrows. J. Am. M. Ass., 
1916, Ixvi, 871. 

Bloodless operation for haemorrhoids and prolapsus ani. 
F.M.Bell. Brit. M. J., 1916, i, 415. 

Liver, Pancreas, and Spleen 

Abscess of the liver and diarrhoea in war. F. Rather 
and L. Bisch. Bull. Acad, de med.. Par., 1916, xxxv, 388. 

Liver wounds due to projectiles in war. Le Fort. 
Presse med., 1916, p. 174. 

GaU-bladder diseases. C. H. Mayo. N. Y. M. J., 
1916, ciii, 433. 

Gall-stone disease. B. T. Tilton. N. Y. M. J., 1916, 
ciii, 436. 

The present status of gall-stone diagnosis by the roent- 
gen ray. F. W. O'Brien. Boston M. & S. J., 1916, 
clxxiv, 309. 

A case of acute gangrenous cholecystitis with spreading 
peritonitis occurring in the epidemic of jaundice, Gallipoli, 
1915. J. MoRLEY and F. B. Smith. Brit. M. J., 1916, i, 
, 444- 



BIBLIOGRAPHY OF CURRENT LITERATURE 



105 



Indications for cholecystetcomy and cholecystostomy. 
C. U. Collins. Illinois M. J., 1916, xxix, 210. [37] 

The pressure or bile secretion during chronic obstruc- 
tion of the common bile-duct. W. T. Mitchell, Jr. and 
R. E. SxiFEL. Bull. Johns Hopkins Hosp., 1916, xxvii, 
78. 

End-results of enterobiliary anastomosis. M. Bazy. 
Bull. Acad. d. med., Par., 1916, Ixxv, 35. [37] 

Uncertainties of understanding anent cholelithiasis. 
C. C. Mapes. Am. J. Surg., 1916, xxx, 54. [37] 

Functioning of pancreas. A. Schmidt. Muenchen. 
med. Wchnschr., 1916, Ixiii, 500. 

Pancreatic stone colic. M. Einhorn. Berl. klin. 
Wchnschr., 1916, liii, no. [38] 

The effect of amino-acids on the pancreatic secretion. 
S. KoBZARENKO. Intcrnat. Beitr. z. Path. u. ther. d. 
Ernaehrungss, 1915, v, 434. 

The spleen; its association with the liver and its relation 
to certain conditions of the blood. W. J. Mayo. J. Am. 
M. Ass., 1916, Ixvi, 716. [38] 

Concretions of the spleen. B. Jablons. Calif. St. J. 
Med., 1916, xiv, 103. 



A case of spontaneous rupture of the malarial spleen. 
W. E. Leighton and F. Moeller. J. Am. M. Ass., 1916, 
Ixvi, 737. 

A study of the lipin content of a case of Gaucher's 
disease in an infant. H. R. Wahl and M. L. Richardson. 
Arch. Int. Med., 1916, xvii, 238. [39] 

An account, with commentary, of a case of splenectomy 
in Addenbrooke's Hospital, Cambridge. C. Allbutt, 
L. Humphry, F. Deighton, and D. C. Hare. Brit. M. 
J., 1916,1,365. 

Splenectomy in chronic anaemias. O. Copello. Rep. 
de Med. y Cir., Bogota, 1916, vii, 262. 

Acute secondary tuberculous splenomegaly; splenec- 
tomy. J. S. Wight. Ann. Surg., Phila., 19 16, Ixiii, 

315. 

A review of the literature on splenectomy. J. W. 
Winston. Virg. M. Semi-Month., 1916, xx, 583. 

Miscellaneous 

Acute abdominal pain. R. P. Bay. Maryland M. 
J., i9i6,lix, 59. 



SURGERY OF THE EXTREMITIES 



Diseases of Bones, Joints, Muscles, Tendons — 

General Conditions Commonly Found 

in the Extremities 

Osteochondritis deformans juvenilis, or Perthe's dis- 
ease. J. H. Gibbon. Ann. Surg., Phila., 1916, Ixiii, 
372. 

Multiple cartilaginous exostoses. A. P. C. Ashhurst. 
Ann. Surg., Phila., 1916, Ixiii, 167. [39] 

Subungual exostosis. A. J. Davidson. Am. J. Orth. 
Surg., 1916, xiv, 150. [40] 

A case of so-called bone cyst of the trochanter. H. J. 
BOGARDUS. J. M. Soc. N. J., 1916, xiii, 129. 

Osteomyelitis of the right femur complicated by fracture 
simulating sarcoma. F. H. Jackson. J. Maine M. Ass., 
1916, vi, 305. 

Leontiasis ossea. F. Leza. Rev. dental, Santiago di 
Chile, 1916, ix, 18. 

The clinical signs of lesions of the sympathetic ap- 
paratus and the vascular apparatus in limb injuries. H. 
Meige and Athanassio-Benisty. Presse med., 1916, p. 

153- 

Syphilitic bursitis, with report of a case. R. W. Scott. 
Am. J. M. Sc, 1916, cli, 386. 

The skeletal lower limbs. K. Shueno. Mitt. a. d. med. 
Fak. d. K. Univ. Tokyo, 1916, xv, 243. 

Tumors over the manubrium and in the left calf. E. 
Cautley. Proc. Roy. Soc. Med., 1916, ix. Sect. Dis. 
ChUd., 35. 

Injury to internal condyle of knee. Walther. Bull, 
et mem. Soc. de chir. de Par., 1916, xlii, 870. 

Retarded ossification as an etiologic factor in traumatic 
arthritis and epiphysitis. J. M. Berry. J. Am. M. Ass., 
1916, Ixvi, 868. [40] 

Treatment of purulent arthritis of the knee by arthros- 
tomy or marsupialization of the synovial sac. G. Fieux. 
Presse m6d., 1916, p. 107. [40] 

Suppurative tibiotarsal arthritis; special inflection of the 
forefoot. E. Qu£nu. Bull. Soc. de chir. de Par., 1916, 
xlii, 816. 

The changed character of later lesions occurring in so- 



called healed tuberculous joints. A. E. Horwitz. J. 
Mo. St. M. Ass., 1916, xiii, 114. 

Meniscus injuries of the knee-joint. G. E. Koujetzny. 
Muenchen. med. Wchnschr., 1916, Ixiii, 525. 

A deposit in the supraspinatus muscle simulating suba- 
cromial bursitis. J. Dunlop. Am. J. Orth, Surg., 1916, 
xiv, 102. [41] 

Rupture of pectoral tendon. A. Bum. Berl. klin. 
Wchnschr., 1916, xxxv, 410. 

Plasterers' corns and bunions. G. F. Boehme, Jr. 
Med. Rec, 1916, Ixxxix, 560. 

Acromegalic gigantism associated with bilateral sym- 
metric syndactylia of the second and third toes. F. 
Battistini. Gior. d. r. Accad. di med. di Torino, 1915, 
Ixxviii, 325. 

Fractures and Dislocations 

Fractures of the neck of the scapula. J. M. Hitzrot 
and R. W. Bolling. Ann. Surg., Phila., 1916, Ixiii, 215. 

[41] 

Treatment of gunshot fractures of the upper extremity 
by means of bridge extension splint. G. Frank. 
Deutsche med. Wchnschr., 1916, xlii, 451. 

A rational treatment for small fractures of the greater 
tuberosity of the humerus. W. M. Brickner. Am. J. 
Surg., 1916, xxx, 77. 

Radical paralysis; complication of a fracture of the 
lower extremity of humerus. E. Huet. Rev. Neurol., 
1916, xxiii, 304. 

Operative treatment of comminuted fracture of the 
lower end of the humerus. G. W. Brock. Am. J. Surg., 
1916, xxx, 83. 

A splint for a fractured humerus. C. Mackenzie. 
Lancet, Lond., 1916, cxc, 674. 

Operation for malunion of fracture of head of radius. 
S. M. Milliken. Med. Rec, 1916, Ixxxix, 493. 

Colles' fracture. J. Reeves. J. Fla. M. Ass., 1916, ii, 
268. 

Treatment of gunshot fractures of hip-joint and thigh. 
Franz. Muenchen. med. Wchnschr., 1916, p. 237. 



io6 



INTERNATIONAL ABSTRACT OF SURGERY 



Artificial impaction of hip fracture. F. J. Cotton. 
Ann. Surg., Phila., 1916, Ixiii, 366. 

Is it possible to obtain bony union in intracapsular 
fractures of the hip-joint? C. H. Lemon. St. Paul M. 
J., 1916, xviii, 86. 

A sign in fracture of the pelvis. G. P. Coopernail. 
Med. Rec, 1916, Ixxxix, 417. 

Gunshot fractures of the extremities. H. Matti. 
Deutsche med. Wchnschr., 1916, xlii, 311. 

The artificial periosteum for fixation of shaft frac- 
tures. J. B. Roberts. Ann. Surg., Phila., 1916, Ixiii, 
182. [41] 

Fracture of the neck of the femur; a study of the treat- 
ment and end-results of 55 cases. A. McGlannan. 
Surg., Gynec, & Obst., 1916, xxii, 287. [41] 

Method of treating oblique fracture of the femur with 
case illustrations. J. S. Wight. Am. J. Surg., 1916, xxx, 
86. 

Thigh fractures healed by Delbet's apparatus. Mar- 
chak. Bull, et mem. Soc. de chir. de Par., 1916, xlii, 
849. . 

Thigh fractures in war. Steberauch. Muenchen. 
med. Wchnschr., 1916, pp. 217, 243. 

Isolated fractures of the tibia, malleolar and marginal. 
J. SiLHOL. Bull, et mem. Soc. de chir. de Par., 1916, xlii, 
819. 

The treatment of fractures of the lower end of the tibia 
and fibula. W. D. Wise. Maryland M. J., 1916, lix, 62. 

Mechanism of fractures in general. F. I. Castro. 
Semaine med., 1916, xxiii, 145. 

Fractures treated by operation. H. W. Drew. Prac- 
titioner, Lond., 1916, xcvi, 256. 

Conservatism in the operative treatment of fractures. 
M. E. Preston. Colo. Med., 1916, xiii, 83. 

The operative treatment of fractures in warfare. A. 
Lane. Practitioner, Lond., 1916, xcvi, 231. 

Some notes on war fractures. G. Taylor. Prac- 
titioner, Lond., 1916, xcvi, 244. 

Three unusual fracture cases, from Frensham Hill 
Military Hospital, Aldershot. S. F. Freyer and J. 
Connell. Practitioner, Lond., 1916, xcvi, 259. 

Congenital elevation of the scapula; a new operation? 
Cubitus varus. F. E. Peckham. Boston M. & S. J., 
1916, clxxiv, 315. 

Recurrent dislocation of the shoulder-joint. J. K. 
Young. Ann. Surg., Phila., 1916, Ixiii, 375. 

Old dislocation of the clavicle in a child. C. H. Bald- 
win. Am. J. Orth. Surg., 1916, xiv, 152. 

Congenital luxation of the right hip- joint; recovery. 
Decree. Semaine med., 1916, xxiii, 203. 

Complete separation and anterior luxation of the 
epiphysis of the left femur. U. S. Kahn. N. Y. M. J., 
1916, ciii, 549. 

Surgery of the Bones, Joints, etc. 

Experiences with the Albee operation in spondylysis 
tuberculosa. O. Vulpius. Muenchen. med. Wchnschr., 
1916, p. 238. 

Experiences in the treatment of infected joints in war. 
H. BuRCKHARDT and F. Landois. Beitr. z. klin. Chir., 
1916, xcviii, 358. [42] 

An overlapping joint as a substitute for cuneiform 
osteotomy. P. Hoffman. Am. J. Orth. Surg., 1916, 
xiv, 96. [43] 

A new procedure in the extraction of projectiles from 
the knee-joint. Kocher. Rev. gen. de clin. et de therap., 
1916, xxx, 239. 

Shoulder abduction splints. F. Cahen. Muenchen. 
med. Wchnschr., 1916, p. 229. 



Preliminary report on device for intramedullary frac- 
ture splinting. E. O. Kane. Internat. J. Surg., 191 6, 
xxix, S3- _ [43] 

Resection of almost the whole of the humerus for 
fistulous osteomyelitis, followed by osseous reproduction 
without shortening and with the production of a new hu- 
meral head. Chaput. Bull, et mem. Soc. de chir. de 
Par., 1916, xlii, 433. [44] 

A statistical study of 539 cases of Pott's disease treated 
by the bone-graft. F. H. Albee. Am. J. Orth. Surg., 
1916, xiv, 134. [44] 

Autoplastic reparation by means of a digital strip in 
some hand injuries. E. Qti^NU. Rev. de chir.. Par., 
1916, XXXV, 20. 

Contracture treatment of short tibial stump. S. 
Hoffmann. Muenchen. med. Wchnschr., 1916, p. 238. 

Homoplastic transplantation of a boiled segment of a 
radius. C. A. McWilliams. Ann. Surg., Phila., 1916, 
Ixiii, 185. [44] 

Tendon-transplantation in infantile paralysis. A. H. 
Freiberg. Lancet-Clin., 1916, cxv, 179. [45] 

Technique of amputation. Frisch. Berl. klin. Wchn- 
schr., 1916, XXXV, 382. 

Amputations; their prevention and after-treatment. 
T. H. Openshaw. Practitioner, Lond., 1916, xcvi, 
284. 

Amputations and prosthetics. Neuhaeuser. Deutsche, 
med. Wchnschr., 1916, xlii, 467. 

How to amputate the index and little fingers. J. S. 
Wight. Med. Times, 1916, xliv, 80. 

The question of amputation in the field and the after- 
treatment of the amputated. G. Seefisch. Deutsche 
med. Wchnschr., 1916, xlii, 446. 

A further study of bone repair. I. Cohn and G. Mann. 
South. M. J., 1916, ix, 235. 

Deformities due to infantile paralysis; operative treat- 
ment. E. W. Ryerson. Am. J. Orth. Surg., 1916, xiv, 
59- . [45] 

Functional result of astragalectomy in infantile paraly- 
sis. R. G. Packard. Colo. Med., 1916, xiii, 93. 

Orthopedics in General 

Orthopedic surgery. C. L. Starr. Canad. J. Med. & 
Surg., 1916, xxxix, 87. 

Deformities of the feet. E. M. Corner. Clin. J., 
1916, xiv, 93. [46] 

The superstition of flat-foot. R. W. Lovett. Pedia- 
trics, 19 16, xxviii, 16. [46] 

Etiology and treatment of equine club-foot. P. 
Hardouin. Rev. de chir., Par., 1916, xxxv, 31. 

Congenital absence of the fibula. A. P. C. Ashhurst. 
Ann. Surg., Phila., 1916, Ixiii, 378. 

The etiology of congenital absence of parts. J. K. 
Young. Lancet-Clin., 1916, cxv, 248. 

Congenital and especially bilateral elevation of the 
scapula. M. Schmidt. Ztschr. f. orthop. Chir., 1915, 
xxxv, Mar. [46] 

A case of Volkmann's ischsemic muscular retraction fol- 
lowing a war injury. L. Verdelet. J. de m€d. de 
Bordeaux, 1916, Ixxvii, 50. 

Results of non-operative treatment of infantile paraly- 
sis. A. O'Reilly. Am. J. Orth. Surg., 1916, xiv, 143. 

[46] 

Continuous extension in very young children. I. D. 
Casadevall. Arch, de ginec, obst. y pediat., 1916, 
xxix, 75. 

Pathogenesis and general etiology of deformities of the 
human body. C. Romans. Riforma med., 1916, xxxii, 
175- 



BIBLIOGRAPHY OF CURRENT LITERATURE 



107 



SURGERY OF THE SPINAL COLUMN AND CORD 



Spina bifida. B. B. Gates. Boston M. & S. J., 1916, 
clxxiv, 420. [47] 

Congenital anterior curvature of the spine; report of case. 
S. Kleinberg. J. Am. M. Ass., 1916, Ixvi, 736. 

Bone-grafting for spinal conditions; report of forty 
cases. J. T. RuGH. Am. J. Orth. Surg.,1916, xiv, 71. [47] 

The syndrome of coagulation massive and xanthochro- 
mic occurring in tuberculosis of the cervical spine. R. S. 
Bromer. Am. J. M. Sc, 1916, cli, 378. 

Lesions of the peripheral nerves and disturbance of 
electric reactions in sections of the cord. P. Mari£ and 
C. FoDC. Rev. Neurol., 1916, xxiii, 313. 

Anatomo-clinical study of a case of total section of the 
spinal cord. H. Claude and J. L'Hermitte. BuU. et 
mem. Soc. med. d. h6p. de Par., 1916, xxxii, 476. [47] 



Dislocation of the first cervical vertebra, produced by 
manipulation. A. F. Jonas. Tr. Am. Surg. Ass., Wash- 
ington, 1916, May. [48] 

Ununited fracture of the lumbar vertebrae. J. K. 
Young. Ann. Surg., PhUa., 1916, Ixiii, 374. 

A painful costovertebral anomaly. Fabre. Rev. 
gen. de clin. et de therap., 1916, xxx, 239. 

Treatment of Pott's disease. J. M. Jorge. Semaine 
med., 1916, xxiii, 319. 

The paraplegias of Pott's disease. J. M. Jorge. 
Semaine med., 1916, xxiii, 268. 

Consideration of Pott's disease. J. M. Jorge. Semaine 
med., 1916, xxiii, 199. 

The treatment of hunchback. R. Falardeau. Union 
med. du Canada, 1916, xlv, 208. 



SURGERY OF THE NERVOUS SYSTEIVI 



Electrical examination of nerve injuries. Lahmann. 
Berl. klin. Wchnschr., 1916, xxxv, 380. 

Lesion of the radial nerve by gunshot; liberation of the 
nerve 1 1 months later without amelioration. C . Walther. 
Bull, et m^m. Soc. de chir. de Par., 1916, xlii, 821. 

Complete section of left radial nerve; nerve-suture; 
return to voluntary movement after 1 50 days. A. Gosset. 
Bull, et m6m. Soc. de chir. de Par., 1916, xlii, 524. [49] 

Gunshot paralysis of the cervical sympathicus. A. 
Gessner. Deutsche med. Wchnschr., 1916, xlii, 465. 

Gunshot injuries of the peripheral nerves. H. Matti. 
Deutsche med. Wchnschr., 1916, xlii, 407. 

Gunshot injuries of the peripheral nerves. Berblinger. 
Muenchen. med. Wchnschr., 1916, Ixiii, 503. 

A sign which accompanies traumatic lesions of the peri- 
pheral nerves. E. Cavazzani. Riv. di patol. nerv. e 
ment., 1916, xxi, 182. 

Inclusion of the radial nerve in a cicatrix; total radial 
paralysis; liberation of the nerve; immediate reappearance 
of motion and sensation. Monsaigeon. Bull, et mem. 
Soc. de chir. de Par., 1916, xlii, 408. [49] 

An operation for the correction of the deformity due to 



obstetrical paralysis. M. H. Rogers. Boston M. & S. 
J., 1916, clxxiv, 163. [49] 

The operative treatment of brachial plexus paralysis. 
W. Sharpe. J. Am. M. Ass., 1916, Ixvi, 876. 

Resection and suture of the sixth cervical root in a case 
of superior radicular paralysis of the brachial plexus. 
Andre-Thomas. Rev. Neurol., 1916, xxiii, 277. 

Late traumatic hemiplegia. Rosanoff-Saloff. Rev. 
Neurol., 1916, xxiii, 301. 

Painful sensation of the skin to pricking, etc., in the 
period of restoration of sectioned nerves. Andr^ -Thomas. 
Rev. Neurol., 1916, xxiii, 311. 

Protection of nerves by a strip of rubber after freeing. 
Le Fort. Presse med., 1916, p. 173. 

The histologic process manifest in the cicatrization and 
functional restoration of traumatized nerves. A. Pitres. 
J. de med. de Bordeaux, 1915, Ixxxvi, 21. 

Nerve-suture after fifteen months with restoration of 
movement. Bittner. Muenchen. med. Wchnschr., 
1916, p. 242. 

Uniting of divided nerves. L. Edinger. Muenchen. 
med. Wchnschr., 1916, Ixiii, 225. [49] 



MISCELLANEOUS 



Clinical Entities — Tumors, Ulcers, Abscesses, etc. 

Cancer investigations. J. C. Bloodgood. Virg. M. 
Semi-Month., 1916, xx, 497. 

The etiology and prophylaxis of cancer. H. T. Byford. 
Illinois M. J., 1916, xxxix, 81. [50] 

Clinical study of 329 cases of cancer subjected to surgical 
ionization. G. B. Massey. Med. Times, 1916, xliv, 100. 

The eclectic treatment of cancer. J. R, Herr. E1- 
lingwood's Therap., 1916, x, 92. 

Treatment of cancer by radio-active substances. T. 
Garmendia. Arch, de ginec, obst., y pediat., 1916, xxix, 

The etiology and prophylaxis of carcinoma. H. T. 
Byford. Chicago M. Recorder, 1916, xxxviii, 138. 



Forty-two cases of inoperable genital carcinoma. 
Ramsauer. Berl. khn. Wchnschr., 1916, xxxv, 380. 

The etiology of sarcoma in the rat. A. S. Leyton 
and H. G. Leyton. Lancet, Lond., 1916, cxc, 513. 

Sarcomata in unusual situations. H. A. Royster. 
N. Y. M. J., 1916, ciii, 492. 

The classification of tumors. C. M. Moullin. Ann. 
Surg., Phila., 1916, Ixiii, 257. [51] 

Phantom tumors. A. P. Allan. Clin. J., 1916, xlv, 
54. [51] 

Pathogenesis of epithelial tumors. K. Yamogiwa 
and K. Ichikawa. Mitt. a. d. med. Fak. d. K. Univ. 
Tokyo, 1915, XV, 295. 

A case of acromegaly with a mediastinal tumor. J. 
Inglis. Colo. Med., 1916, xiii, 92. 



io8 



INTERNATIONAL ABSTRACT OF SURGERY 



Immune reactions against tumor-growth in animals 
with spontaneous tumors. M. S. Leisher and L. Loeb. 
J. Med. Research, 1916, xxxiv, i. 

Three unusual cyst cases. H. H. Hines. Lancet-Clin., 
1916, cxv, 277. 

Furuncles. J. Leverett. Med. Council. 1916, xxi, 36. 

The modern treatment of burns. G. De Tarnowsky. 
J. Cutan. Dis., 1916, xxxiv, 191. 

New treatment for burns. H. R. Slack. J. M. Ass. 
Ga., 1916, V, 153. 

A further note on the etiology of surgical scarlatina. 
J. B. Roberts. Tr. Am. Surg. Ass., Washington, 1916, 
May. _ [51] 

Unusual surgical cases. L. F. Stewart. Internat. 
J. Surg., 1916, xxix, 72. 

Surgical shock. R.D.Campbell. J.-Lancet,i9i6,xxxvi, 
135- 

Sera, Vaccines, and Ferments 

Two new cases of poliomyelitis cured by intrarachidian 
injections of serum from earlier cases. A. Netter and 
M. Salanier. Bull, et mem. Soc. med. d. h6p. de Par., 
1916, xl, 299. 

Treatment of fistulous osteites by the polyvalent serum 
of Leclamche and Vallee. A. Mouchet. Bull, et mem. 
Soc. de Chir. de Par., 1916, xlii, 898. 

The ventral inclined position in the serum treatment of 
cerebrospinal meningitis. F. Ramond. Bull, et mem. 
Soc. med. d. h6p. de Par., 1916, xl, 297. 

Intraventricular injections after or without trepanation 
for cerebrospinal meningitis. Netter. Bull. Acad, de 
med.. Par., 1916, Ixxv, 322. 

Action of pituitary extract. R. G. Hoskins. J. Am. 
M. Ass., 1916, Ixvi, 733. 

Some observations regarding coUargol injections in small 
doses. Gellhaus. Muenchen. med. Wchnschr., 1916, 
Ixiii, 191. [52] 

Blood 

The preservation of living red blood-cells in vitro; 
methods of preservation. P. Rous and J. R. Turner. 
J. Exp. Med., 1916, xxiii, 219. [52] 

Origin and status of so-called transitional white blood- 
cell. F. A. Evans. Arch. Int. Med., 1916, xvii, i. 

Tissue cellular protein poisons. J. G. Gumming and 
J. S. Chambers. J. Lab. & Clin. Med., 1916, i, 428. 

The practical application of blood-pressure findings. 
J. J. Rowen, Jr. J. Am. M. Ass., 1916, Ixvi, 873. 

Chronic syphilitic aoritis. J. C. Lyter. J. Mo. St. 
M. Ass., 1916, xiii, 103. 

Endovenous coprotherapy. M. A. Marini. Semaine 
med., 1916, xxiii, 143. 

Secondary haemorrhage in military surgery. W. H. 
MoRRiss. Mil. Surgeon, 1916, xxxviii, 131. [52] 

The blood and the blood-vessels in haemophilia and other 
haemorrhagic diseases. A. F. Hess. Arch. Int. Med., 
1916, xvii, 203. [53] 

Prothrombin and antithrombin factors in the coagula- 
tion of blood. G. R. MiNOT, G. P. Denny, and D. Davis. 
Arch. Int. Med., 1916, xvii, loi. 

The conservative treatment of gangrene of the extrem- 
ities due to thrombo-angiitis obliterans. W. Meyer. Ann. 
Surg., Phila., 1916, Ixiii, 280. [53] 

Venous thrombosis and embolism, its cause, significance, 
and consequences. A. McLean. Penn. M. J., 1916, 
xix, 318. _ .... [54] 

The operative treatment of thrombo-angiitis obliterans. 
C. F. Painter. St. Paul. M. J., 1916, xviii, 41. [55] 

A case of thrombo-angiitis obliterans. E. Evans. 
Wis. M. J., 1916, xiv, 430. 



Continuous transfusion; the production of immunity. 
A. Kahn. Med. Rec, 1916, Ixxxix, 553. 

Reactions following blood transfusion by the syringe 
cannula system. E. Lindeman. J. Am. M. Ass., 1916, 
Ixvi, 624. [55] 

The relation of haemolysis in the transfusion of babies 
with the mothers as donors. T. H. Cherry and E. G. 
Langrock. J. Am. M. Ass., 1916, Ixvi, 626. [56] 

The preservation of living red blood-cells in vitro; 
transfusion of kept cells. P. Rous and J. R. Turner. 
J. Exp. Med., 1916, xxiii, 239. [56] 

Blood and Lymph Vessels 

A clinical lecture on aneurisms of war wounds. W. M. 
EccLES. Am. J. Surg., 1916, xxx, ^2. [56] 

A case of ruptured syphilitic aneurism with treponema 
pallida stained in situ. F. S. Graves. Lancet-Clin., 
1916, cxv, 245. 

The epicrises in wound aneurisms. H. F. O. Haber- 
LAND. Deutsche med. Wchnschr., 1916, xlii, 160. [57] 

A case of traumatic femoral arteriovenous aneurism. 
E. A. Supple. Boston M. & S. J., 1916, clxxiv, 352. 

An unusual form of gunshot arteriovenous aneurism in 
which the sac was situated on the side opposite to the vein. 
C. A. Morton. Lancet, Lond., 1916, cxc, 557. 

Arteriovenous aneurism of the bifurcation of the right 
primitive carotid and internal jugular. H. Rouvillois. 
Bull, et mem. Soc. de chir. de Par., 1916, xlii, 580. 

An unusual mode of rupture of aneurism, explained by 
discovery of its dissecting nature. F. D. Weidman. 
Am. J. M. Sc, 1916, cli, 427. 

Two cases of aneurism due to bullet wouftds. C. A. 
Ball. Med. Press & Circ, 1916, ci, 214. 

Cirsoid aneurism. E. S. Judd. St. Paul M. J., 1916, 
xviii, 48. [57] 

Aneurism of the arteria femoralis due to stenosis. 
W. Kausch. Berl. klin. Wchnschr., 1916, xxxv, 364. 

Cure of popliteal aneurism and illustrative case. P. 
Martin. Indianapolis M. J., 1916, xix, 93. 

Experience in injuries of the large blood-vessels in war. 
H. Kuettner. Berl. klin. Wchnschr., 1916, liii, loi. [57] 

Ligation of the lingual artery in Beclard's and Pirogoff's 
triangles. Rev. de med. y cir., Habana, 1916, xxi, 149. 

Lacing the lingual artery for secondary haemorrhage of 
the tongue. L. Moncalvi. Policlin., Roma, 1916, 
xxiii, sez. prat., 273. 

Failure of an arterial suture. Coutealtd. Bull, et 
mem. Soc. de chir. de Par., 1916, xlii, 696. 

Bacteria associated with certain types of abnormal 
lymph-glands. J. C. Torrey. J. Med. Research, 1916, 
xxxiv, 65. 

Reversal of the circulation in the lower extremity. J. 
S. Horsley. Ann. Surg., Phila., 1916, Ixiii, 277. 

Digest of the scope of vascular surgery. N. W. Sharpe. 
Internat. J. Surg., 1916, xxix, 69. 

Poisons 

Chronic general infection with the bacillus pyocyaneus. 
L. Freeman. Tr. Am. Surg. Ass., Washington, 1916, 
May. [58] 

The reactions between bacteria and animal tissues under 
conditions of artificial cultivation; bactericidal action in 
tissue cultures. H. F. Smyth. J. Exp. Med., 1916, 
xxiii, 265. 

The reactions between bacteria and animal tissues under 
conditions of artificial cultivation; action of bacterial 
vaccines on tissue cultures in vitro. H. F. Smyth. J. 
Exp. Med., 1916, xxiii, 275. 



BIBLIOGRAPHY OF CURRENT LITERATURE 



109 



The reactions between bacteria and animal tissues 
under conditions of artificial cultivation; cultivation of 
tubercle bacilli with animal tissues in vitro. H. F. Smyth. 
J. Exp. Med., 1916, xxiii, 283. 

Report of a case of tetanus, with complications. J. S. 
Gaumer. J. Am. M. Ass., 1916, Ixvi, 739. 

Remarks on delayed tetanus. G. Barling. Brit. M. 
J., 1916, i, 337. [58] 

The treatment of tetanus. R. G. Abercrombie. 
Brit. M. J., 1916, i, 339. [58] 

Iodine in tetanus. A. T. MacConkey and S. S. Zilva. 
Brit. M. J., 1916, i, 411. 

A case of tetanus cured by the negro method. L. 
Isnardi. Gior. d. r. Accad. di med. di Torino, 1915, 
kxviii, 354. 

Mental symptoms complicating a case of acute tetanus 
during treatment by carbolic injections. J. Everidge. 
Brit. M. J., 1916, i, 443. 

Surgical Therapeutics 

The newer things in surgery. C. E. Kahlke. Clinique, 
1916, xxxvii, 93. 

The post-hospital care of a surgical patient. S. Mc- 
GuiRE. South. M. J., 1916, ix, 251. [59] 

A new method of treating tuberculous and other chronic 
infected sinuses. W. O, Sweek. Interst. M. J., 1916, 
xxiii, 225. 

Surgical Anatomy 

Critical observations and experimental researches on the 
regeneration and new formation of the lymph-glands. 
A. Vecchi. La Clin. Chir., Milano, 1916, No. 90. 

The effect of phloridzin on tiunors in animals. F. C. 
Wood and E. H. McLean. J. Cancer Research, 1916, i, 
49- . . . [59] 

Experimental alterations produced by the micrococcus 
melitensis. R. Brancati. Policlin., Roma, 1916, xxiii, 
sez. chir., 65. 

Relation of bacterial capsule to virulency. Reichen- 
BACH. Berl. klin. Wchnschr., 1916, xxxv, 380. 

Contributions to the experimental surgery of the 
mediastinum (excluding the heart). O. Uffreduzzi. 
Am. Med., 1916, xxviii, 89. [59] 

The theory of muscle contracture. R. DuBois-Rj;y- 
MOND. Berl. klin. Wchnschr., 1916, xxxv, 392. 

Some attempts to produce exophthalmos experimentally. 
A. Troell. Arch. Int. Med., 1916, xvii, 382. 

The clinical study of oedema by means of the elasto- 
meter. A. B. Schwartz. Arch. Int. Med., 1916, xvii, 
396. [60] 

Pathological aspects of some problems of experimental 
cancer research. J. Ewing. J. Cancer Research, 1916, 
i, 71. . . . . . [60] 

The uric acid solvent power of luine after administra- 
tion of piperazine, lysidin, lithium carbonate, and other 
alkalies. H. D. Haskins. Arch. Int. Med., 1916, xvii, 
405. [60] 

Contribution to the study of urinary chemistry in ex- 
perimental tuberculosis of the rabbit. E. Lapin. Rev. 
de la tuberc, 1916, xi, 392. 

Pharmacology of the ureter; action of epinephrin, ergo- 
toxin, and nicotine. D. I. Macht. J. Pharmacol. & 
Exp. Therap., 1916, viii, 155. 

Radiology 

Some exp)eriences with the Coolidge tube in the treat- 
ment of superficial malignancies. W. R. Cleveland. 
Lancet-Clin., 1916, cxv, 233. 



Blue filtration of the quartz-lamp light. Thedering. 
Muenchen. med. Wchnschr., 1916, Ixiii, 494. 

Apparatus for ultra-violet ray treatment. Axmann. 
Berl. klin. Wchnschr., 1916, liii, 431. 

The results of combined mercury-lamp and deep X-ray 
treatment of human lung tuberculosis. A. Bacmeister. 
Deutsche med. Wchnschr., 1916, xlii, 99. [61] 

The organization of the X-ray department of a general 
hospital in France. A. H. Pirie. .A.rch. Radiol. & 
Electrotherap., 1916, xx, 332. 

Experimental grounds for treatment of lung tuberculosis 
by X-rays. Kuepferle and Bacmeister. Deutsche 
med. Wchnschr., 1916, xlii, 96. [61] 

A method of locating buried needles. W. F. Jordan. 
West. M. Times, 1916, xxxv, 426. 

The cooling of roentgen tubes by means of boiling water. 
R. Fuerstenau. Deutsche med. Wchnschr., 1916, xlii, 
418. 

Bullet locating and roentgen measurement without 
apparatus. P. Krause. Berl. klin. Wchnschr., 1916, 
xxxv, 362. 

Exact localization of foreign bodies by means of roentgen 
rays. Hammes and Schoepf. Deutsche med. Wchnschr., 
1916, xlii, 252. [62] 

The diagnosis of abdominal pathology as revealed by 
roentgen ray. J. W. Frank. Hahneman. Month., 
191O, li, 177. 

The proper filter for deep roentgen therapy. H. Wintz 
and L. Baumeister. Muenchen. med. Wchnschr., 1916, 
Ixiii, 189. [61] 

Roentgen treatment of deep-seated cancer. J. T. Case. 
Physician & Surg., 1915, xxxvii, 442. [62] 

Alimentary roentgenology. E. H. Skinner. West. 
M. Times., 1916, xxxv, 413. 

Five hundred gastro-intestinal examinations by roent- 
gen rays. R. H. Millwee. Texas M. News, 1916, xxv, 

415- 

The improved trochoscope as a diagnostic and roentgeno- 
scopic operating table. C. K.\estle. Muenchen. med. 
Wchnschr., 19 16, Ixiii, 493. 

Some radiiun physics. C. W. Hanford. Chicago M. 
Recorder, 1916, xxxviii, 143. [62] 

A convenient radiimi emanation table for clinical work. 
W. C. Stevenson. Arch. Radiol. & Electrotherap., 
1916, XX, 335. 

Radium; a recognition of its efficicency and a plea for 
more thorough investigation. D. C. Moriarta. Med. 
Rec, 1916, Ixxxix, 410. 

The uses and limitations of stereoscopic radiography 
in the diagnosis of injury to bone; the after-treatment of 
fractures as carried out in the electrical department of the 
Cambridge Hospital, Aldershot. F. Hern.aman- Johnson. 
Practitioner, Lond., 1916, xcvi, 249. 

Radiologic exhibition of a fistulous tract by means of a 
simple and unproved technique. Holyknecht, Lilien- 
feld, and Pordes. Berl. klin . Wchnschr., 1916, liii. 

The normal stomach; its size, position, form, tone, peri- 
stalsis, and mobility from a radiographic standpoint. C. 
W. Perkins. Med. Press & Circ, 1916, ci, 258. 

The action of radiimi on transplanted tumors of ani- 
mals. F. C. Wood and F. Prime, Jr. Ann. Surg., 
Phila., 1915, Ixii, 751. [62] 

Radiology by a zero method giving immediately the 
depth of the projectile to be localized. G. Andrault. 
Progres m6d., 1916, p. 54. 

Radiography of the chest in children. W. J. S. By- 
thell. Arch. Radiol. & Electrotherap., 1916, xx, 321. 

Therapeutic effects of radium. D. T. Quigley. J.- 
Lancet, 1915, xxxv, 653. [63] 



INTERNATIONAL ABSTRACT OF SURGERY 



The fifth lumbar vertebra of adults in the radiograph. 
S. JiNNAKA. Mitt. a. d. med. Fak. d. K. Univ. Tokyo, 
1916, XV, 345- 

Some radium achievements. H. A. Kelly. Am. J. 
Surg., 1916, XXX, 73. 

The significance of the radiographs of the Piltdown teeth. 
W. C. Lyne. Proc. Roy. Soc. Med., 1916, ix, Odontol. 
Sect., s^. 

Radiologic contribution to the diagnosis and cure of 
wounds. M. PoNzio. Gior. d. r. Accad. di med. di 
Torino, 1915, Ixxvii, 418. 

The radiology of war; a transportable apparatus. F. 
DI Cavallerleone. Gior. d. r. Accad. di med. di Torino, 

1915, Ixxviii, 331. 

Report on the radium treatment at the Royal Infirmary, 
Edinburgh, during the year 191 5. D. Turner. Edinb. 
M. J., 1916, xvi, 204. 

A new medium for pyelography. A. A. McConnell. 
Med. Press & Circ, 1916, ci, 238. [63] 

Military Surgery 

Sinusitis of the face due to projectiles. Guisez and 
OuDOT. Presse med., 1916, p. 129. 

Dental prothesis in the surgery of war. P. Martinier 
and M. Roy. Rev. dental, Santiago di Chile, 1915, viii, 
240. 

Gunshot wounds in the upper limbs. E. Delorme. 
Practitioner, Lond., 1916, xcvi, 261. 

Fibrillar muscular spasm after gunshot injury of the 
lumbosacral plexus. Filkelnburg. Deutsche med. 
Wchnschr., 1916, xlii, 433. 

The effects of high explosives upon the central nervous 
system. F. W. Mott. Lancet, Lond., 1916, cxc, 331, 
441. [63] 

MiUtary gunshot wounds. C. Richard. N. Y. St. J. 
Med., 1916, xvi, 108. 

A lucky wound. C. H. Reinhold. Indian M. Gaz., 

1916, li, 87. 

The septicity of projectiles in cicatrized wounds. Prat. 
Bull, et mem. Soc. de chir. de Par., 1916, xlii, 622. 

Study of shell shock; certain disorders of cutaneous 
sensibility. C. S. Myers. Lancet, Lond., 1916, cxc, 608. 

Discussion of shell shock without visible signs of in- 
jury. F. W. Mott, W. McDougall, W. Brown, and 
others. Proc. Roy. Soc. Med., 1916, ix. Sect. Psychiat. 
& Neurol., i. 

Penetrating wounds by pointed instruments. Brun- 
ZEL. Berl. klin. Wchnschr., 1916, xxxv, 399. 

Traumas of war; the stomatological service in the zone 
of war. R. Avanzi. Stomatol., Milano, 1916, xiv, 41. 

Dermatoses developed about war wounds and fistulous 
tracts. A. Desaux. Presse med., 1916, p. 138. 

Some notes on shrapnel bullet wounds. S. Wickenden. 
Practitioner, Lond., 1916, xcvi, 298. 

Osteoma of aviators. Vorbe and Rocher. Rev. 
g6n. de clin. et de therap., 1916, xxx, 248. 

Gunshot wounds of the soft parts. B. Vincent and 
R. B. Greenough. Boston M. & S. J., 1916, clxxiv, 153. 

[63] 

Gunshot retention wounds. M. Flesch. Beitr. z. 
klin. Chir., 1916, xcviii, 400. 

Gas bacillus infection. A. M. Fauntleroy. West. 
M. News, 1916, viii, 51. 

Statistics of 14 cases of gaseous gangrene, treated by 
ether dressings. Marchak. Bull, et mem. Soc. de chir. 
de Par., 1916, xlii, 846. 

Diagnosis and treatment of gaseous gangrene. A. 
Chalier. Progres med., 1916, p. 41. 

Bacteriological and experimental researches on gas 



gangrene. M. Weinberg. Lancet, Lond., 1916, cxc, 
622. [64] 

Gaseous gangrene and a conservative operative method 
of treatment. U. Camera. Gior. d. r. Accad. di med. 
di Torino, 1915, Ixxviii, 432. 

Notes on war surgery. A. M. Forbes. Brit. M. J., 
1916,1,369. 

The treatment of gunshot wounds. B. Moynihan. 
Brit. M. J., 1916, i, 333. _ [65] 

Removal of bullets and other metallic foreign bodies. 
R. G. P. Lansdown. Bristol Med.-Chir. J., 1915, xxxiii, 
157. 

Three cases of field surgery. G. Matronola. Clin. 
chir., Milano, 1916, No. i, 121. 

The principles of treatment and their application to 
wounds. C. F. M. Saint. Brit. M. J., 1916, i, 367. 

Secondary closing of wounds. Carrel, Dehelly, 
and Dumas. Brit. M. J., 1916, i, 211. [65] 

Physical treatment for disabled soldiers. J. Camus. 
Lancet, Lond., 1916, cxc, 691. 

The biologic conception of the curability of infected 
wounds. E. Bertarelli. Gazz.d.osp.ed. clin., Milano, 
1916, xxxvii, 369. 

Some elementary rules relative to the treatment of sup- 
purating wounds in war. L. B£rard and A. Lumue;re. 
Rev. de chir., 1916, xxxiv, 445. [66] 

Sodium hypochlorite in the treatment of septic wounds. 

F. J. A. Dalton. Brit. M. J., 1916, i, 126. [66] 
The immediate cure of wounds made by hand bombs 

and grenades. L. Dominci. Clin, chir., Milano, 1916, 
No. I, 114. 

Some notes on the treatment of the Turkish wounded 
from the Suez Canal. F. C. Madden. Lancet, Lond., 
1916, cxc, 613. 

The ship surgeon. E. A. Jockardy. Am. Med., 1916, 

xi, I74-. 
The- importance of general principles in military surgery. 

G. G. Turner. Brit. M. J., 1916, i, 401 . 

The case recording of wounds in war. A. W. Sheen. 
Clin. J., 1916, xlv, 109. 

The rate of mortality in the British Army 100 years 
ago. A. Chaplin. Proc. Roy. Soc. Med., 1916, ix, Sect. 
History Med., 89. 

Snowshoes for transportation of the wounded. Trapp. 
Muenchen. med. Wchnschr., 1916, p. 230. 

Health of armies in peace and war. Lancet, Lend., 
1916, cxc, 517. [66] 

Preparations of the naval medical department for battle. 
A. Farenholt. Mil. Surgeon, 1916, xxxviii, 281. 

Work at a base hospital. W. Rankin. Brit. M. J., 
1916,1,371. 

War surgery experiences in a field hospital. Kappis. 
Berl. klin. Wchnschr., 1916, xxxv, 381. 

The American clean-up of Serbia. G. A. Lurie. Am. 
J. Clin. Med., 1916, xxiii, 209. 

Surgical Pathology 

Some present-day problems in surgery. N. F. Fallon. 
Boston M. & S. J., 1916, clxxiv, 407. 

Surgical problems considered from the standpoint of 
morbidity. E. H. Ochsner. Illinois M. J., 1916, xxix, 
161. 

Operative mortality. L. Razetti. Gac. med. de 
Caracas, 1916, xxiii, 17. [67] 

Urticaria an,d pseudo-appendicitis. E. Apert. Monde 
med., 1916, xxvi, 65. [67] 

The value of various diagnostic methods for the cere- 
brospinal fluid. H. Nakano. J. Cutan. Dis., 1916, xxxiv, 
179. 



BIBLIOGRAPHY OF CURRENT LITERATURE 



III 



Morphologic alterations of the tubercle bacillus in the 
clinically distinct forms of the disease. Blanco. Se- 
maine med., 1916, xxiii, 379. 

Unrecognized syphilitic lesions surgically operated as 
cancers or as local tuberculosis. Gaucher. Ann. d. 
mal. v6n.. Par., 1916, xi, 153. [67] 

Surgery and syphilis, j. H. Carstens. Illinois M. J., 
1916, xxix, 198. 

Hospital, Medicolegal, and Medical Education 

Medical experts in our courts. C.F.Buckley. Pacific 
M. J., 1916, lix, 138. 

Liability for wrong diagnosis and treatment. J. Am. 
M. Ass., 1916, Ixvi, 764. 

Death from having chloroform administered by person 
neither physician nor trained nurse. (Roughlin vs. 
State [Ga.] 86 S. E. R. 452). J. Am. M. Ass., 1916, 
lx\n, 836. 



Breaking of stitches and opening of wound not covered 
by accident insurance. (Stokely vs. Fidelity & Cas- 
ualty Co. of New York [Ala.], 69 So. R. 64.) J. Am. 
M. Ass., 1916, Ixvi, 836. 

Movable kidney — its medicolegal significance. W. W. 
Crawford. South. M. J., 1916, ix, 261. 

Sufficient evidence of malpractice in treatment of 
fracture. (Wilk vs. Black [Mich.], 154 N. W. R. 561.) 
J. Am. M. Ass., 1916, Ixvi, 836. 

The duties of medical practitioners in cases of criminal 
abortion. Brit. M. J., 1916, i, 206. [68] 

Roentgen-ray plates may be shown to juries. (Lutton 
vs. Southern Express Co. [N. C], 86 S. E. R. 614.) 
J. Am. M. Ass., 1916, Ixvi, 982. 

Corporation surgery. S. C. Beach. Am. J. Clin. 
Med., 1916, xxiii, 236. 

Some medical and surgical experiences at Miraj Hos- 
pital. W. J. Wanless and C. E. Vail. Indian M. Gaz., 
1916, li, 92. 



GYNECOLOGY 



Uterus 

Cervical laceration. D. Forster. J. Fla. M. Ass., 
1916, ii, 266. 

Lacerated cervix. R. T. Goodwin. Texas St. J. Med., 
1916, xi, 542. [69] 

Intermediate trachelorrhaphy as a prophylactic against 
the pernicious effects sometimes caused by lacerations of the 
cervix. H. J. Boldt. Am. J. Obst., N. Y., 1916, Ixxiii, 
543- 

Some essential points in the treatment of carcinoma of 
the uterine cervix. E. W. Jones. J.-Lancet, 1916, 
xxxvi, 160. 

The problem of heat as a method of treatment in in- 
operable uterine carcinoma. J. F. Percy. Tr. Am. 
G>'nec. Soc, Washington, 1916, May. [69] 

Adenocarcinoma of the uterus and carcinomatous gall- 
bladder. H. J. Boldt. Am. J. Obst., N. Y., 1916, Ixxiii, 
543- 

A case of fibroid tvunor of the uterus complicated by 
pregnancy; myomectomy; recovery. R. B. Hall. Lan- 
cet-CIin., 1916, cxv, 254. 

Uterine fibrosis. J. O. Polak. Am. J. Obst., N. Y., 
1916, Ixxiii, 509. 

Gangrenous interstitial fibroids. L. G. Baldwin. 
Am. J. Obst., N. Y., 1916, Ixxiii, 488. 

Radium treatment of uterine fibroids. J. and J. L. 
Ransohoff. Lancet-Clin., 1916, cxv, 116. [70] 

The meaning and mechanism of menstruation. F. 
Hare. Clin. J., 1916, xlv, 105, 120. 

Compensatory (vicarious, ectopic) menstruation; xeno- 
menia; memmes devii. W. H. Condit. Am. J. Obst., 
N. Y., 1916, Ixxiii, 238. [70] 

Recent results in the X-ray treatment of menorrhagia, 
dysmenorrhoea, and uterine myoma. S. Lange. Am. J. 
Roentgenol., 1916, iii, 72. [71] 

Four uteri the seat of chronic inflammation. H. J. 
Boldt. Am. J. Obst., N. Y., 1916, Ixxiii, 542. 

Septic uterus. E. S. Judd. Am. J. Obst., N. Y., 1916, 
Ixxiii, 511. 

Procidentia uteri in a nullipara. J. F. Keenan. Brit. 
M. J., 1916,1,343. 



An operation for retrodisplacement of the uterus. A. 
S. A. W. Collins. Am. J. Surg., 1916, xxx, 92. [71] 

Surgical treatment of retrodisplacements of the uterus. 
J. A. Hill. Texas M. J., 1916, xxxi, 354. 

Clinical aspect of the double uterus in its relation to 
diagnosis and treatment. M. Handfield- Jones. Lancet, 
Lond., 1916, cxc, 574. [71] 

Uterus bicornis unicollis; abscess in right comu; am- 
putation; normal pregnancy in left cornu. H. Arranow. 
Med. Rec, 1916, Ixxxix, 539. 

Uterine surgery. A. M. Judd. Med. Times, 1916, 
xliv, 78. 

The removal of the troublesome useless uterus. A. E. 
Gallant. N. Y. M. J., 1916, ciii, 485. [72] 

Adnexal and Periuterine Conditions 

Technique by which conservatism is made possible in 
diseases of the adnexa. P. B. Salatich. Am. J. Surg., 
1916, xxx, 90. 

The relation of angiogenesis to ossification, based upon 
the study of five cases of calcification and ossification of 
the ovary. E. Moschcowitz. Bull. Johns Hopkins 
Hosp., 1916, xxvii, 71. [73] 

Infection of ovarian dermoid cyst with typhoid bacil- 
lus. A. L. O'Shansky. J. Am. M. Ass., 1916, Ixvi, 888. 

[74] 

Fibrocyst of ovary with suppurating tubo-ovarian cyst 
on the opposite side. H. J. Boldt. Am. J. Obst., N. Y., 
1916, Ixxiii, 542. 

Twisted ovarian cyst complicated with pregnancy; 
simulating symptoms of renal calculus; apparent corrobora- 
tion by roentgen picture. H. N. Vineberg. Am. J . 
Obst., N. Y., 1916, Ixxiii, 486. 

The end-results of resection of the ovaries for micro- 
cystic disease. J. A. McGlinn. Am. J. Obst., N. Y., 
1916, Ixxiii, 435. 

Strangulated fallopian tube, ovary, and intestine in an 
infant. G. Abelio. J. Am. M. Ass., 1916, Ixvi, 813. 

Salpingitis secondary to appendicitis. J. E. Moore. 
Surg., Gynec. &Obst., 1916, xxii, 277. [74] 



112 



INTERNATIONAL ABSTRACT OF SURGERY 



External Genitalia 

Syphilis of the internal genital organs in the female. G. 
Gellhorn and H. Ehrenfest. Tr. Am. Gynec. Soc, 
Washington, 191 6, May. [74] 

Vesicovaginal fistulae. H. Smith. Indian M. Gaz., 
1916, li, 98. 

A case of pseudohermaphrodism, with remarks on 
abnormal function of the endocrine glands. W. C. 
QuiNBY. Bull. Johns Hopkins Hosp., 1916, xxvii, 50. 

A case of relaxed vesical sphincter with incontinence of 
urine cured by the Kelly operation. H. D. Furniss. 
Med. Rec, 1916, Ixxxix, 538. 

Miscellaneous 

Progress in gynecology. S. Rushmore. Boston M. 
& S. J., 1916, clxxiv, 320. 

Morphine and scopolamine in gynecological surgery. 
W. F. Morrison. Am. J. Obst., N. Y., 1916, Ixxiii, 439. 

Gangrene of the lower extremities after gynecological 
and obstetrical operations. A. Stein. Am. J. Obst., 
N. Y., 1916, Ixxiii, 537. 

Haemorrhagic pelvic peritonitis; hysterectomy. A. H. 
Harrigan. Am. J. Obst., N. Y., 1916, Ixxiii, 533. 

Perineal repair, with report of a case. B. L. Sulz- 
BACHER. N. Mex. M. J., 1916, XV, 207. 



Surgical treatment of gonorrhoeal tube infection with a 
quarantine pack. R. C. Coffey. Surg. Gynec. & Obst., 
1916, xxii, 228. ■ [77] 

The relation of the mammary glands to nervousness 
and menstruation. E. B. Block. J. M. Ass. Ga., 1916, 

V, 155- 

Experimental researches on the mechanism of menstrua- 
tion. H. ViGNES. Ann. de gynec. et d'obst.. Par., 1916, 
xlii, 104. 

Precocious menopause in virgins. A. Farani. Arch. 
bras. d. med., 1916, v, 287. 

A report of several cases of chorio-epithelioma following 
vesicular mole. C. Lockyer. Lancet., Lend., 1916, cxc, 
514- 

Borderline between operation and non-operation in 
gynecology and obstetrics. Kronig. Deutsche med. 
Wchnschr., 1916, xlii, 435. 

The correlation between the olfactory and genital func- 
tions in the human female. J. A. Hagemann. Med. 
Press & Circ, 1916, ci, 195. 

End-results of the first 171 consecutive abdominal 
operations for pelvic disease in women; standardization 
of the surgeon. G. P. Laroque. Old Dominion J., 
1916, xxii, 60. 

Some remarks regarding useless, therefore undesirable, 
operations. G. A. Van Leeuwex. Arch. mens, d'obst. 
et de gynec, 1916, iv, 433. [77] 



OBSTETRICS 



Pregnancy and Its Complications 

Diagnosis of pregnancy by way of the urine. E. B. 
Knerr. J. Mo. St. M. Ass., 1916, xiii, loi. 

A urinary test for pregnancy. F. Klein and C. H. 
Walker. N. Yorker med. Monatschr., 1916, xxvi, 95. 

A quantitative test for the Abderhalden reaction. L. 
Van Slyke and Vinograd-Villchur. Am. J. Obst., 
N. Y., 1916, Ixxiii, 290. [78] 

A case of ectopic gestation and appendicitis. F. M. 
Neild. Lancet, Lond., 1916, cxc, 676. 

Ectopic gestation; rupture; operation; recovery. S. 
Gaster. Indian M. Gaz., 1916, li, 99. 

Ruptured interstitial ectopic pregnancy complicated by 
a large ovarian cyst. A. H. Harrigan. Am. J. Obst., 
N. Y., 1916, Ixxiii, 534. 

Ruptured ectopic pregnancy, simulating pelvic infection. 
A. H. Harrigan. Am. J. Obst., N. Y., 1916, Ixxiii, 532. 

Extra-uterine pregnancy. A. P. Heineck. Elling- 
wood's Therap., 1916, x, 82. 

Ruptured tubal pregnancy. H. M. Torrington. 
Canad. M. Ass., J., 1916, vi, 232. 

Interstitial gestation. M. C. Waegeli. Rev. de 
gynec. et de chir. abdom.. Par., 1916, xxiii, 405. 

Eclampsia. D. J. Evans. Canad. M. Ass. J., 1916, 
vi, no, 234. [78] 

Eclampsia: studies concernijng its causes, nature, and 
treatment. H. E. Diehl. N. Eng. M. Gaz., 1916, li, 
72. [78] 

Caesarean section. E. Field. J. M. Soc. N. J., 1916, 
xiii, 115. 

Vaginal caesarean section. A. Stein. Am. J. Obst., 
N. Y., 1916, Ixxiii, 535. 

Delivery by the natural passages following caesarean 



section; report of two cases. J. T. Williams. Am. J. 
Obst., N. Y., 1916, Ixxiii, 425. 

Caesarean section — overdone. F. S. Kellogg. Bos- 
ton M. & S. J., 1916, clxxiv, 454. 

Modern indications for caesarean section. J. T. Wil- 
liams. Boston. M. & S. J., 1916, clxxiv, 450. 

Indications for the advantages of the high incision in 
caesarean section. F. H. Raab. J. Mo. St. M. Ass., 1916, 
xiii, 76. [79] 

Caesarean section in a Pitman's cottage. R. G. Bell. 
Brit. M. J., 1916, i, 195. [79] 

Segmental suprasymphyseal caesarean section. E. 
Zarate. Semaine med., 1916, xxiii, 263. 

Caesarean section; a consideration of indications, tech- 
nique and time of operating. C. M. Green. Boston 
M. & S. J., 1916, clxxiv, 441. 

The lower uterine segment, its origin and boundaries. 
E.H. Tweedy. Lancet, Lond., 1916, cxc, 565. [79] 

Abortion with expulsion of the placenta at the third 
month; full- term baby at nine months (probable twin 
pregnancy). H. Arranow. Med. Rec, 1916, Ixxxix, 

539. 

A case of retention of a dead foetus. R. D. Castans. 
Rev. de cien. med., Barcel., 1916, xlii, 97. 

Twin pregnancy in a horn of a bicornuate uterus with 
retention of the foetuses for twenty years. E. Scott and 
J. FoRMAN. Am. J. Obst., N. Y., 1916, Ixxiii, 570. 

A note on superfoetation. A. Kuntz. Interst. M. J., 
1916, xxiii, 204. 

Surgical treatment of placenta praevia. E. L. Beck. 
J. Arkansas M. Soc, 1916, xii, 251. 

The prenatal problem and the influence which may favor- 
ably affect this period of the child's growth. M. West. 
Am. J. Obst., N. Y., 1916, Ixxiii, 416. 



BIBLIOGRAPHY OF CURRENT LITERATURE 



"3 



A case of meningeal haemorrhage observed in the course 
of pregnancy and labor, followed by recovery. Fabre 
and BouRCET. Ann. de gyn^c. et d'obst., Par., 1916, xlii, 
118. 

The systolic blood-pressure in pregnancy; observations 
on five thousand consecutive cases in the pregnancy clinic 
of the Boston Lying-in Hospital. F. C. Irving. J. Am. 
M. Ass., 1916, Ixvi, 935. [80] 

Labor and Its Complications 

Labor obstructed by ovarian cyst. W. Salisbury. 
Brit. M. J., 1915,1,514. 

Ovarian cyst obstructing labor. H. Arranow. Am. 
J. Obst., N. Y., 1916, Ixxiii, 530. 

Rupture of the uterus sustained during version, un- 
recognized until prolapse of the intestines forty-eight 
hours later. T. H. Cherry. Med. Rec, 1916, Ixxxix, 

576. . 

Premature separation of normally situated placenta 
due to shortening of the cord. G. W. Kosmak. Med. 
Rec, 1916, Ixxxix, 576. 

Gas bacillus infection following futile attempts at in- 
duction of labor. T. H. Cherry. Med. Rec, 1916, 
Ixxxix, 577. 

Report of eight cases of transverse presentation. H. L. 
Woodward. Lancet-Clin., 1916, cxv, 256. 

Subcutaneous symphyseotomy. E. Zarate. Se- 
maine med., 1916, xxiii, 379. 

The high forceps operation. S. E. Wichmann. Nord. 
med. Ark., Stockholm, 1916, Kirurgi, Nos. i and 2, pp. 
I, 131- . [80] 

The fundamental principles underlying the use of the 
obstetric forceps. J. X. Bell. J. Mich. St. M. Soc, 

I916, XV, III. 

Vagitus uterinus. R. D. Wolfe. Virg. M. Semi- 
Month., 1916, XX, 587. 

Painless childbirth. E. A. Abernethy. Virg. M. 
Semi-Month., 1916, xx, 578. 

Pituitrin in labor. J. J. Mundell. Am. J. Obst., 
N. Y., 1916, Ixxiii, 306. [81] 

Experience with pituitrin in obstetrics. F. O. Yost. 
South. Calif. Pract., 1916, xx.xi, 60. 

Abuse of pituitrin. J. Arte ag a. Arch, deginec, obst. 
y pediat., Barcel., 1916, Xo. 6, 123. 

The uses of pituitary extract in labor at the Govern- 
ment Maternity Hospital, Madras. C. A. F. Hingston. 
Indian M. Gaz., 1916, li, 81. 

Twilight sleep. J. W. Duncan, C. Holbrooke, and 
G. W. Phelan. Canad. M. Ass. J., 1916, vi, 97. 

Some experience with twilight sleep. W. J. Bltidell. 
J. So. Car. M. Ass., 1916, xii, 81. 

Daemmerschlaf, or twilight sleep. I. H. Adams. J. 
M. Ass. Ga., 1916, v, 163. 

Scopolamine amnesia, or twilight sleep. C. A. Ferris. 
Colo. Med., 1916, xiii, 88. 

Analgesia and anaesthesia in obstetric practice. A. J. 
Skeel. J. Am. M. Ass. 1916, Ixvi, 797. [81] 

Chloroform h\-pnosis and manual aid during protracted 
and painful labor. P. R. Cooper. Clin. J., 1916, xlv, 
83. 

A case of retention of the placenta after birth. F.\bre 
and Rheuter. Ann. de gynec. et d'obst.. Par., 1916, 
xlii, 120. 

Case of dystocia of the shoulders after disengaging the 
head. A. Farani. Arch. bras, de med., 1916, v. 542. 

The high forceps operation. S. E. Wichmann. Nord. 
Med. Ark., Stockholm, 1916, Kirurgi, Xos. i and 2, i, 131. 

Delay in breech presentations from extension of the legs. 
R. Jardine. Glasgow M. J., 1916. lx.x.xv, 81. 



The technique at the Jewish Maternity Hospital and its 
results. J. Walker. Am. J. Obst., X. Y., 1916, Ixxiii, 
429. 

Puerperium and Its Complications 

A peculiar case of intra-abdominal abscess. H. D. 
FuRNiss. Med. Rec, 1916, Ixxxix, 538. 

Erythema nodosum as post-partum complication. 
L. A. Wing. Med. Rec, 1916, Ixxxix, 576. 

Puerperal septicaemia treated by intravenous injection 
of eusol. A. T. Brand and J. R. Keith. Brit. M. J., 
1916,1,4x5. 

The puerperal fever fiction and the notification farce. 
W. E. FoTHERGiLL. Lancet, Lond., 1916, cxc, 506. 

Treatment of puerperal infections. P. Jung. Deutsche 
med. Wchnschr., 1916, xlii, 405. 

Thrombophlebitis of the superior longitudinal sinus and 
of the external cerebral veins on the twenty-second day 
after labor. Commandeur. Ann. de gyn€c. et d'obst.. 
Par., 1916, xlii, 116. 



Miscellaneous 



Am. J 
J 



Is the midwife a necessity? J. M. Baldy. 
Obst., N. Y., 1916, Ixxiii, 399. 

Supervision of the midwife. J. C. Edgar. Am 
Obst., X. Y., 1916, Ixxiii, 386. 

Modern conceptions regarding induced premature labor 
on account of contracted pelvis. G. Guicci.\rdi. Ann 
di ostet. e ginec, 1916, xxxviii, 789. 

Criminal abortion. Schottmlt:ller. Deutsche med 
Wchnschr., 1916, xlii, 338. 

Criminal abortion with particular reference to its sup- 
pression in East Prussia. Benthin. Berl. klin 
Wchnschr., 1916, xxxv, 410. 

A case of meningeal haemorrhage in the newborn 
VoRON and Rey. Ann. de gynec et d'obst.. Par., 1916, 
xlii, 119. 

A case of fatal cerebral haemorrhage occurring in a new- 
born infant, following breech delivery. R. Y. Sullivan. 
Virg. M. Semi-Month., 1916, xx, 510. 

Cystic hygroma in an infant. M. H. V. Cameron. 
Canad. M. Ass. J., 1916, vi, 137. 

Treatment of ophthalmia neonatorum. L. M. Francis. 
Buffalo M. J., 1916, Ixxi, 344. [81] 

Treatment of gonorrhoeal ophthalmia. C. Barnert. 
Med. Rec, 1916, Ixxxix, 239. [81] 

Two cases of intestinal haemorrhage in the newborn. 
M. M. Cr.\wford. Med. Press & Circ, 1916, ci, 283. 

Injuries to the infant, produced at birth. C. R. Han 
NAH. Texas St. J. Med., 1916, xi, 539. [82] 

Xursing. L. Verney. Clin, ostet., Roma, 1916, Xo. 
5, 81. 

Maternal feeding. J. I. Dutiand. Xorthwest Med., 

I916, XV, 89. 

Progress toward ideal obstetrics. J. B. De Lee. 
Am. J. Obst., X. Y., 1916, Ixxiii, 407. 

The progress of obstetrics in the year 1914. P. Z. 
Manueco. Arch, de ginec, obst. y ped., 1916, xxix, loi. 

Anaesthesia in obstetrics. A. Brant. Boston M. & 
S. J., 1916, clxxiv, 458. 

Xitrous o.xide in obstetrics. F. C. Irving. Boston 
M. & S. J., 1916, clxxiv, 462. 

Syphilis in its relation to obstetrics. E. P. D.wis. 
Tr. Am. Gynec. Soc, Washington, 1916, May. 82] 

The influence of syphilis on the chances of progeny. 
X. B. Harman. Brit. M. J., 1916,1, 196. 

Forceps in the first half century after introduction in 
obstetrics. Irgerzler. Monatschr. f. Geburtsh. u. 
Gynaek., 1915, xlii, Dec 



114 



INTERNATIONAL ABSTRACT OF SURGERY 



GENITO-URINARY SURGERY 



Adrenal, Kidney, and Ureter 

Some phases of calculous disease of the kidney and 
ureter. P. M. Pilcher. Long Island M. J., 1916, x, 89. 

The diagnosis and treatment of infection of the urinary 
tract. W. W. Cobb. Texas St. J. Med., 1916, xi, 588. 

Pyuria, a symptom; its causes and diagnosis. D. 
Newman. Glasgow M. J., 1916, Ixxxv, 161. 

Subphrenic abscess. J. N. Hall. Colo. Med., 19 16, 
xiii, 76. 

The inner secretion of the kidney and its relation to the 
regulation of sugar. T. Ita Kura. Mitt. a. d. med. Fak. 
d. K. Univ. Tokyo, 1916, xv, 197. 

Clinical review of 240 cases of non-surgical infection of 
the kidneys and ureters. G. J. Thomas. Urol. & Cutan. 
Rev., 1916, XX, 127. [84] 

Three unusual kidhey cases. S. F. Wilcox. J. Am. 
Inst. Homoeop., 1916, viii, 993. 

A method of demonstrating bacteria in urine by means 
of this centrifuge; the relative value of examinations 
by culture or stained sediment. E. G. Crabtree. Surg., 
Gynec. & Obst., 1916, xxii, 221. [84] 

Pyelitis in infancy and early childhood. L. R. De Buys. 
South. M. J., 1916, ix, 197. 

The r61e of urine stasis in the etiology of pyogenic kid- 
ney infections. L. E. Schmidt. Lancet-Clin., 1916, 
cxv, 118. ... . [84] 

An unusual case of kidney ripping by a grenade splinter. 
F. Danziger. Berl. klin. Wchnschr., 1916, liii, 160. [85] 

War injuries of the urogenital system. Stutzin and 
GuNDELFiNGER. Deutsche med. Wchnschr., 1916, xlii, 
188,227. _ .... [85J 

Large congenital hydronephrosis in an infant six weeks 
of age. M. S. Kakels. N. Y. M. J., 1916, ciii, 547. [85] 

Essential hematuria. S. Englander. Cleveland M. 
J., 1916, XV, 105. 

Unilateral haematuria. J. Ransohoff. Surg., Gynec. 
& Obst., 1916, xxii, 275. [86] 

Cases of renal tuberculosis illustrating modern methods 
of diagnosis. H. S. Jeck. Nashville J. M.& S. ,1916, cx, 97. 

The periods of amelioration in renal tuberculosis. C. 
Macedo. Cr6n. med., Lima, 1916, xxxii, 33. [86] 

The clinical importance of unilateral fused kidney; in- 
cluding the distopic kidney of one side. A. Stein. Am. 
J. Obst., N. Y., 1916, Ixxiii, 449. 

Danger of pyelography. M. Simmonds. Muenchen. 
med. Wchnschr., 19 16, Ixiii, 229. [86] 

The newer methods of diagnosis in the surgery of the 
kidney. D. N. Eisendrath. Chicago M. Recorder, 
1916, xxxviii, 160. 

Functional tests of the kidneys. W. H. Deaderick. 
Med. Herald, 1916, xxxv, 81. 

Renal function tests. J. R. Lehmann. Texas St. J. 
Med., 1916, xi, 584. 

Phenolsulphonephthalein as a functional test in kidney 
diagnosis. K. Goto. Mitt. a. d. med. Fak. d. K. Univ. 
Tokyo, 1916, XV, 387. 

Clinical consideration of Ambard's constant. V. 
Grossi. Policlin., Roma, 1916, xxiii, sez. chir., 41. [86] 

Intravenous injections of lactose without reaction; 
Sclayer's kidney test. Wechselmann. Berl. klin. 
Wchnschr., 1916, liii, 84. [87] 

The phenolsulphonephthalein estimation of renal func- 
tion in a thousand cases. M. H. Wyman. J. So. Car. 
M. Ass., 1916, xii, 84. [87] 



Congenital double hydro-ureter. E.Pritchard. Proc. 
Roy. Soc. Med., 1916, ix, Sect. Dis. Child., 38. 

Ureteral stricture; excluding cases due to tuberculosis 
and calculus; report of fifty cases. G. L. Hunner. Tr. 
Am. Urol. Ass., St. Louis, 1916, April. [87] 

Five cases of ureteral fistula. H. D. Furniss. Am. 
J. Obst., N. Y., 1916, Ixxiii, 528. 

Bladder, Urethra, and Penis 

General principles of the technique of lithotrity. F. 

Legueu. Rev. gen. de clin. et de therap., 1916, xxx, 228. 

Some problems in the X-ray diagnosis of urinary calculi. 

C. W. Woodall. Albany M. Ann., 1916, xxxvii, 116. [89] 
Impacted vesical calculus. C. Goodman. Med. Rec, 

1916, Ixxxix, 493. 

Bladder affections in women. H. D. Furniss. Am. J. 
Obst., N. Y., 1916, Ixxiii, 489. 

Cauterization and fulguration of bladder tumors. 
H. A. Kelly and W. Neill. J. Am. M. Ass., 1916, 
Ixvi, 721. [89] 

Cystitis and its treatment. G. H. Candler. Am. J. 
Clin. Med., 1916, xxiii, 227. 

The injuries to the bladder. W. H. Cary. Am. J. 
Obst., N. Y., 1916, Ixxiii, 492. 

The operative treatment of bladder incontinence. 
ScHULTZE. Berl. klin. Wchnschr., 1916, xxxv, 366. 

Experience with Makka's operation for ectopia of the 
bladder. H. Freund. Beitr. z. klin. Chir., 1916, xcix, 99. 

[89] 

Urinary peritoneal inundation; reparatory power of the 
bladder. E. Magni. Policlin., Roma, 1916, xxiii, sez. 
prat., 434. 

The use of suction in the post-operative treatment of 
bladder cases. J. W. Churchman. Bull. Johns Hopkins 
Hosp., 1916, xxvii, 69. 

Report of a calculus in the fossa navicularis urethrae. 
J. D. Morgan. Arch. Radiol. & Electrotherap., 1916, xx, 

341- 

Modern methods of urethral mspection. J. T. Windell. 
Urol. & Cutan. Rev., 1916, xx, 143. 

Urethral diverticula. C. W. Ginn. J. Am. Inst. 
Homoeop., 1916, viii, 1025. 

The association of urethral catheterization and radiog- 
raphy in the diagnosis of affections of the urethra, renal 
pelvis, and kidney. M. Seres. Rev. med. de SeviUa, 
1916, Ixvi, 129. 

Double urethra with operation: review of literature. 

D. W. Mackenzie. Surg., Gynec. & Obst., 1916, xxii, 
344. 190] 

Genital Organs 

Choice of operative method in the cure of hydrocele. 
N. Federici. Gazz. d. osp. e d. clin., Milano., 1916, 
xxxvii, 339. 

Anatony amd pathology of the seminal vesicles. E. O. 
Smith. Urol. & Cutan. Rev., 1916, xx, 76. [90] 

Tuberculosis of the seminal duct. H. W. Plaggemeyer. 
J. Mich. St. M. Soc, 1916, XV, 118. 

Tuberculosis of the seminal vesicle and epididymis. 
H. W. Plaggemeyer. Urol. & Cutan. Rev., 1916, xx, 
134. [91] 

Treatment of non-tuberculous inflammations of the 
seminal duct. R. W. Staley. Urol. & Cutan. Rev., 
1916, XX, 131. [91] 



BIBLIOGRAPHY OF CURRENT LITERATURE 



"5 



Precocious prostatic hypertrophy, clinically revealed by 
a month and a half sojourn in the trenches. Loumeau. 
J. de mdd. de Bordeaux, 1916, Ixxvii, 97. 

The prognosis of prostatis. M. Silverberg. Calif. 
St. J. Med., 1916, xiv, 60. [92] 

The best technique of suprapubic prostatectomy. J. 
Krauss. J. Am. Inst. Homoeop., 1916, viii, ioi6. 

Suprapubic prostatectomy under local anaesthesia. 
R. L. Payne. Am. J. Surg., 1916, xxx, 88. 

Some features of importance in the diagnosis and prog- 
nosis of urogenital tuberculosis. J. F. McCarthy. Surg. 
Gynec. & Obst., 1916, xxii, 330. [92] 

A case of hermaphroditism. J. E. Middlemiss. 
Lancet, Lond., 1916, cxc, 675. 



Miscellaneous 

Examination of the urinary tract by the roentgen ray. 
W. C. Barker. J. Am. Inst. Homoeop., 1916, viii, 1022. 

The diagnosis of genito-urinary tuberculosis. J. W. 
Churchman. Med. Rec, 1916, Ixxxix, 511. 

Hexamethylenamine as a urate solvent and diuretic, 
and its effect on the reaction of urine. P. J. Hanzlik. 
J. Labor. & Clin. Med., 1916, i, 321. [92] 

Haematuria and its treatment. C. J. Drueck. Am. 
J. Clin. Med., 1916, xxiii, 214. 

Genito-urinary symptoms arising from anal, rectal, 
and colonic diseases, and vice versa. A. J. Zobel. J. 
Am. M. Ass., 1916, Ixvi, 496. [93] 



SURGERY OF THE EYE AND EAR 



Eye 

A simple apparatus for removal of foreign bodies from 
the eye. Richter. Muenchen. med. Wchnschr., 19 16, 
p. 246. 

Foreign body embedded in the optic nerve; not removed; 
globe preserved. L. Emerson. Arch. Ophth., 1916, 
xlv, 199. 

The American method of cataract extraction. J. San- 
tos-Fernandez. Med. Rec, 1916, Ixxxix, 517. 

Congenital cataract — hereditary influences. R. H. 
Gantt. South. M. J., 1916, ix, 266. 

Some unusual types of cataract operation. R. A, Fen- 
ton. Northwest Med., 1916, xv, 80. 

Digital compression of the lacrymal sac in dacryocystitis 
of the newborn especially. J. Fernandez. Rev. de 
med. y cir. de la Habana, 1916, xxi, 141. 

The prognosis in sympathetic ophthalmia. P. Dunn. 
Lancet, Lond., 1916, xcx, 620. 

Report of a case of epithelioma of the lower eyelid. S. 
B. Moon. J. Ophth., Otol. & Laryngol., 1916, xxii, 253. 

Abscess of the lower eyelid and internal angle of the eye, 
of dental origin. L. M. Guitta. Odontologia, Madrid, 
1916, XXV, 65. 

Sarcoma of the iris. F. W. Irwin. Arch. Ophth., 
1916, xlv, 196. 

Burns of the eye; prognosis and treatment. A. Terson. 
Rev. g6n. de clin. et de th6rap., 1916, xxx, 225. 

Epibulbar epithelioma of the right eye. Garcia. 
DEL Mazo. Siglo med., 1916, Ixiii, 189. 

Rosacea keratitis and certain other forms of marginal 
keratitis, neurophatic in origin; treatment by pericorneal 
neurotomy. F. H. Verhoeff. Arch. Ophth., 1916, xlv, 
148. , [94] 

Surgical treatment of strabismus. Viciano. Siglo 
m6d., 1916, Ixiii, 131. 

Treatment of gonococcis conjunctivitis by autogenococ- 
cic serum. T. L. Dehogues. Rev. d. m6d. y cir. de la 
Habana, 1916, xxi, 99. [94] 

Conservation of vision and prevention of blindness. 
G. E. DE ScHWEiNiTZ. Med. Press. & Circ, 1916, ci, 

215- 

The rational treatment of traumatic corneal ulcers. 
M. R. DiNKELSPiEL. Med. Council, 1916, xxi, 31. 

Ependymitis; report of a subacute case cured by lumbar 
puncture. A. C. Snell and J. Roby. N. Y. St. J. Med., 
1916, xvi, 148. 



Melanic sarcoma of the choroid. Moya. Siglo med., 
1916, Ixiii, 188. 

Bacteriological and clinical studies of an epidemic of 
Koch-Weeks bacillus conjunctivitis associated with cell 
inclusion conjunctivitis. H. Noguchi and M. Cohen. 
Arch. Ophth., 1916, xlv, 155. 

Tenotomy of the inferior oblique muscle. W. C. Posey. 
Arch. Ophth., 1916, xlv, 137. 

Inopportune operations. E. Valude, Ann. d'ocul., 
1916, cliii, 89. 

Restoration of the socket. W. B. Weidler. Arch. 
Ophth., 1916, xlv, 195. 

Injuries of the eyes and the care of those blinded in war. 
Silex. Deutsche med. Wchnschr., 1916, xlii, 465. 

Ophthalmological errors in the field. R. Rauch. Berl. 
klin. Wchnschr., 1916, liii, 113. 

The ophthalmology of war. Forster. Berl. klin. 
Wchnschr., 19 16, xxxv, 380. 

Ophthalmology in North America and in the Argentine 
Republic. I. S. Fernandez. Semaine med., 1916, p. 
364- 

Ear 

Some fatal ear cases in the writer's practice during the 
past year. O. D. Stickney. J. Ophth., Otol. & Laryngol., 
1916, xxii, 189. 

Perforations of ShrapneU's membrane. H. V. F. 
Clay. J. Ophth., Otol. & Laryngol., xxii, 242. 

Aural complications of influenza. S. M. Smith. 
Therap. Gaz., 1916, xl, 165. [94] 

An unusual case of brain abscess of otitic origin. E. E. 
Maxey. Northwest Med., 1916, xv, 88. 

Ventilation of the eustachian tubes. H. Hays. Med. 
Times, 1916, xliv, 93. 

Report of a case of acute mastoiditis, with influenzal 
meningitis; treatment by operation on the mastoid and 
anti-influenzal serum. F. R. Packard. Tr. Am. Otol. 
Soc, Washington, 1916, May. [94] 

Acute mastoiditis with unusual symptoms indicative of 
intracranial involvement; operation; recovery. E. B. 
Dench. Tr. Am. Otol. Soc, Washington, 1916, May. 

[94] 

Obscure cases of mastoid involvement. E. B. Dench. 
N. Y. M. J., 1916, ciii, 529. [95] 

Report of a case of suppurative mastoiditis without 
tympanitis. W. S. Tomlin. Indianapolis M. J., 1916, 
xix, 95. 



ii6 



INTERNATIONAL ABSTRACT OF SURGERY 



SURGERY OF THE NOSE, THROAT, AND MOUTH 



Nose 

Sinusitis. I. B. Viliesid. Rev. dental, Santiago di 
Chile, 1916, ix, 7. 

The diagnosis and treatment of inflammatory affections 
of the nasal accessory sinuses. C. A. Veasey. North- 
west Med., 1916, XV, 73. [96] 

War injuries of the nasal accessory cavities. Kuettner. 
Berl. klin. Wchnschr., 1916, xxxv, 375. 

Gunshot injuries of the accessory cavities. Laubschat. 
Berl. klin. Wchnschr., 1916, xxxv, 377. 

A case of tubercular leprosy involving the upper air 
passages. H. Aerowsmith. Laryngoscope, 1916, xxvi, 
188. 

Carcinomata of the nasopharynx. W. E. Gatewood. 
J. Am. M. Ass., 1916, Ixvi, 499. [96] 

Migraine. A. H. Molina-De Saint Remy. N. Y. M. 
J., 1916, ciii, 588. [96] 

Papilloma of the nose. J. G. Callison. Laryngo- 
scope, 1916, xxvi, 153. [96] 

Deaths attributable to intranasal operations and other 
instrumentation. V. Dabney* Surg., Gynec. & Obst., 
1916, xxii, 324. _ [97] 

Submucous resection of the nasal septum. C. G. 
Stivers. South. Calif. Pract., 1916, xxxi, 57. 

Submucous resection of the nasal septum. W. J. 
Blackburn. J. Ophth., Otol. & Laryngol., 1916, xxii, 
228. _ [97] 

Correction of depressed nasal deformity of the trans- 
plantation of conjoined bone and cartilage. W. W. 
Carter. Med. Rec, 1916, Ixxxix, 421. 

A galvanocautery operation for the lower turbinate. 
G. Sluder. Laryngoscope, 1916, xxvi, 166. [97] 

The treatment of atrophic rhinitis by paraffin injections. 
F. B. Kellogg. J. Ophth., Otol. & Laryngol., 1916, 
xxii, 218. 

An improved submucous operation. F. B. Kellogg. 
J. Ophth., Otol. & Laryngol., 1916, xxii, 215. [98] 

Head haemorrhage. F. C. Sage. J. Ophth., Otol. & 
Laryngol., 1916, xxii, 246. 

Throat 

Views on the tonsil question. J. T. Henessy. Hosp. 
Bull. Univ. Md., 1916, xii, 6. 

The conservative treatment of the tonsils. G. Hudson- 
Makuen. N. Y. M. J., 1916, ciii, 483. 

A simple tonsil operation under local anaesthesia. H. 
Hays. Med. Rec, 1916, Ixxix, 419. [98] 

The question of age in tonsillectomy. T. L. Shearer. 
J. Ophth., Otol. & Laryngol., 1916, xxii, 205. [98] 

Observations in tonsillectomy some years after opera- 
tion. B. R. Shurley. J. Mich. St. M. Soc, 1916, xv, 
116. 

Removal of tonsils and adenoids in diphtheria carriers. 
S. A. Friedberg. J. Am. M. Ass., 1916, Ixvi, 810. [98] 

Studies on diphtheria; the treatment of diphtheria 
carriers by tonsillectomy. H. O. Run, M. J. Mill, and 
R. G. Perkins. J. Am. M. Ass., 1916, Ixvi, 941. 



The occurrence of abscess of the lung after tonsillectomy. 
M. Manges. Am. J. Surg., 1916, xxx, 78. 

Fibroma of larynx. Haenisch. Berl. klin. Wchnschr , 
1916, xxxv, 381. 

Gunshot injuries of larynx. Schsier. Berl. klin. 
Wchnschr., 1916, xxxv, 375. 

True myxoma of the rhinopharynx; report of two cases. 
V. Dabney. Virg. M. Semi-Month., 1916, xx, 594. 

Roentgen diagnoses of diseases of the upper air passages. 
J. J. Kyle. West. M. Times, 1916, xxxv, 416. 

A case of foreign body in the throat of a child three and 
one-half months old. C. M. Robertson. Laryngoscope, 
1916, xxvi, 192. 

Paper clip in bronchus seventeen years removed by 
superior bronchoscopy. E. Beer. J. Am. M. Ass., 1916, 
Ixvi, 739. 

Subglottic stricture. R. W. Moore. Texas St. J. 
Med., 1916, xi, 599. 

Infra-epiglottal cysts. G. M. Landa. Rev. d. med. 
y cir. de la Habana, 1916, xxi, 97. 

Mouth 

Injury to the soft palate and uvula in tonsillectomies. 
J. A. Thompson. Laryngoscope, 1916, xxvi, 196. 

An unusual dental case simulating antral sinusitis. 
H. B. Decherd. Laryngoscope, 1916, xxvi, 194. 

Tuberculosis and its principal dentobuccal complications. 
E. A. Dam. Rev. dental, Santiago di Chile, 1916, ix, 3. 

Some pathologic cases of dental impaction. L. Gio- 
VANCCHiNi. Odonto Colomb., Bogota, 1915, vi, 137. 

The dental path; its importance as an avenue of infec- 
tion. T. B. Hartzell and A. T. Henrici. St. Paul 
M. J., 1916, xviii, 77. 

A dental view of the present treatment of pyorrhoea 
alveolaris. W. O. Talbot. Texas St. J. Med., 1916, xi, 
590- 

Clinical case of alveolar abscess. F. E. Hart. Rev. 
dental, Santiago di Chile, 1915, viii, 268. 

Oral sepsis as a focus of infection. B. C. Darling. 
Am. J. Roentgenol., 1916, iii, 158. 

Fistula of the tongue due to foreign body after gunshot 
injury. Thost. Deutsche med. Wchnschr., 1915, xlii, 
337. 

Tuberculosis of the tongue. L. Durante. Ann. Surg., 
Phila., 1916, Ixiii, 143. [98] 

Abscess of the tongue. J. V. White. J. Mich. St. 
M. Soc, 1916, XV, 114. 

Phlegmonous retrolingual angina; septic subhyoidean 
phlegmon. Petges, Rocher and Peyri. Presse m6d., 
1916, p. 175. 

Treatment of cancer of the tongue and mouth. J. S. 
Horsley. Virg. M. Semi-Month., 1916, xx, 500. 

Phlegmons of the floor of the mouth. A. E. de Aragon. 
Rev. dental, Santiago di Chile, 1916, ix, 102. 

A case of phlegmon of the mouth. A. R. Vargas. 
Odontologia, Madrid, 1916, xxv, 82. 

Sialolithiasis and sialodochitis in childhood. H. 
Neuhof. Am. J. Dis. Child., 1916, xi, 232. 



INTERNATIONAL 
ABSTRACT OF SURGERY 

AUGUST, 1916 



COLLECTIVE REVIEW 



A CRITICAL REVIEW OF THE LITERATURE PERTAINING 
RELATION BETWEEN GYNECOLOGICAL AND 
NEUROLOGICAL CONDITIONS 

By RICHARD R. SMITH, M.D., F.A.C.S., Grand Rapids, Michigan 



TO THE 



THE present-day broader opinions of gyne- 
cologists in regard to the relationship 
between gynecological and neurological 
conditions are grounded to a considerable extent 
on what has gone before. To give an intelligible 
account of them, it has seemed to me necessary 
to review historically the literature which has 
been accumulating ever since the beginning of 
modern gynecology, back in the seventies and 
eighties. Before this time ideas relative to this 
subject were so vague and illy defined that for 
our purpose they may be discarded, though they 
had a certain amount of influence on later-day 
conceptions. 

As I look over the literature as a whole I am 
tempted to divide it into three groups: 

1 . A group made up largely of older papers and 
accounts in which a very close and direct associa- 
tion between abnormal conditions in the pelvis 
and neurological disturbances was assumed. 

2. A group based upon experience which 
showed the fallacy of such older views. 

3. A group which must include some of the 
modern purely neurological hterature pertaining 
to the nature of the neuroses, and a few gyneco- 
logical papers that have been influenced by it. 

It is necessary to say, in presenting a subject 
so complex and one concerning which there is 
still so much to be learned, that there has been 
in the past and is today much dissension from 
prevailing ideas, especially those that seem dog- 
matic and extreme. There is no question, how- 



ever, but that at various periods certain ideas 
have prevailed to such an extent as to influence in 
varying degrees the practice of those engaged in 
gynecological work. 

Modern operative gynecology began with 
plastic operations upon the cervix and vagina. 
An immense amount of attention was directed 
to this field, in which it was found possible to be 
of so much service to women. It is perhaps only 
natural that the importance of such lesions be- 
came magnified. Lacerations and displacements 
were soon made responsible, not only for much 
local discomfort but for remote pain, various 
disturbances of many body functions, and for 
serious conditions of the central nervous system, 
including hysteria, epilepsy, and insanity, with- 
out much reference to the complexity and defi- 
nition of any of these. 

Group I. Storer (i) (note also the subsequent 
discussion) as long ago as 1869, in the first volume 
of the American Journal of Obstetrics, in his 
description of a case of "obstinate erotomania," 
and the various attacks that were made upon the 
clitoris, vulva, and rectum of this patient, as 
well as the more general physical measures em- 
ployed, shows well the state of professional opin- 
ion of those days, and how ready medical men 
were to go to extremes when once the importance 
of pelvic disorders in the human economy had 
been pointed out. 

Emmett (2) in 1874 called the attention of the 
profession to cervical lacerations "as a frequent 



117 



ii8 



INTERNATIONAL ABSTRACT OF SURGERY 



cause of disease," and in 1876 (3), at the first 
meeting of the American Gynecological Society, 
he called attention to "uterine flexures," which 
he believed were of much importance. 

At the same meeting Skene (4) (1876), in his 
reported cases of uterine and vaginal cicatrices, 
showed clearly his belief in such lesions as a cause 
of neurological conditions. 

Emmett, himself, as near as I can learn, never 
emphasized the importance of these lesions as the 
cause of serious nervous disturbances, though in 
discussing Skene's paper he made the statement 
that cicatrical tissue in the cervix was a frequent 
cause of neuralgia in females, and ascribed it to 
the inclusion of nerve filaments in the scar. 

Engelmann (5) in 1877 read a paper in which he 
expressed a strong belief in "uterine derange- 
ments" as the cause of hysteroneurosis. The 
paper is typical of some of the extreme views of 
that period. He says: "By the term hystero- 
neuroses I would designate those phenomena 
which simulate a morbid condition of an organ, 
unaccompanied by any structural sympathetic 
hyperasthesia, due to uterine derangements and 
demonstrated to be unquestionably so dependent 
by being intractable to direct local medication, 
but yielding at once upon treatment of the casual 
pelvic disorder." 

Fallen (6) in 1877 stated that diseases of the 
pelvic organs were a most important cause of 
insanity, and Edis (7) in 1881 (four years later) 
gave out his belief that headaches, the morning 
sickness of pregnancy, uterine epilepsy, asthma, 
chorea, amaurosis, and other disturbances of 
vision, aphonia, spasm of the glottis, sensation of 
choking, and other similar reflex phenomena 
could be ascribed to uterine conditions. There 
were dissenting opinions from such extreme 
views, even at that time, seen occasionally in the 
discussions (see paper by Bigelow [8], 1881), 
but nevertheless such opinions, modified accord- 
ing to the individual observer, prevailed very 
largely and were the basis for acceptance of simi- 
lar views in regard to the ovaries and tubes which 
now in the development of abdominal surgery 
gradually received the chief attention of the 
profession. 

Skene's (9) paper in 1881 is especially valuable 
in indicating the various directions into which dis- 
cussion was to run after the injection of this newer 
element into pelvic problems, for gynecologists 
were now dealing with an important ductless 
gland. 

It was not until the eighties that operations 
upon the appendages for inflammatory diseases 
became popular, and during that decade papers 



and discussions dealing with indications and 
methods occupied a prominent place in gyneco- 
logical literature. To cure certain pelvic infec- 
tions, and thereby to remove a physical ailment, 
was the original indication for such operations, 
and with mgfny gynecologists the appendages 
were never or rarely removed except to cure some 
definite and perfectly apparent pelvic disorder. 
With others, however, the indications were ex- 
tended, as had been the case with vaginal and 
cervical lacerations, to meet many remote mor- 
bid conditions, especiaUy those of the nervous 
system. 

As early as 1877 Battey (10) proposed the re- 
moval of both ovaries with the deliberate inten- 
tion of ending ovulation and menstruation. 
The operation was for a long time spoken of as 
"Battey's operation." His indications included 
not only certain malformations of the female 
genitalia which were incompatible with health, 
but cases of insanity and epilepsy "depending 
upon uterine and ovarian disease," and "in 
cases of long and protracted physical and mental 
suffering dependent upon nervous and vascular 
conditions and perturbations which have resisted 
all means of cure." Battey opened the cul-de-sac 
through the vagina and removed the ovaries, 
leaving the tubes. He performed his first opera- 
tion of the kind in 1872 (11). 

It was not, however, until the early eighties, 
as stated, that the indications for removal of the 
appendages were commonly extended to remote 
disturbances in the nervous system. In Car- 
stens' (12) article (1883) we see an example of a 
commonly expressed opinion of the day. He cites 
three cases of " hystero-epilepsy " in which Bat- 
tey's operation was performed (in one instance 
only one ovary), and expresses firm belief in it. 
Johnson's (13) case of epilepsy in which the 
ovaries were removed is another example of the 
same idea. 

Lee (14) in 1887 (note also discussion), at a meet- 
ing of the Obstetrical Society of New York, pre- 
sented the ovaries from a woman suffering from 
a "hysteromania," and in the discussion follow- 
ing, behef in such a procedure was plainly ex- 
pressed, although Munde said that the removal 
of ovaries for ipental affections was still sub 
judice. 

Byford (15) in 1888, before the Chicago Gyneco- 
logical Society, exhibited specimens of ovaries, 
and showed his belief in their removal for mental 
affections. 

All through this early period, then, we find 
many indications ot a widely prevaihng belief 
in the idea that nervous affections of many kinds 



SMITH: GYNECOLOGICAL AND NEUROLOGICAL CONDITIONS 



119 



arose with great frequency directly from patho- 
logical conditions in the pelvis, real or supposed, 
or in some disturbances of function there. I 
think it is fair to say that a goodly percentage of 
gynecologists accepted these views to a greater or 
lesser extent. 

We do not find until the early nineties distinct 
signs of a reaction — increased experience and 
disappointment were teaching that this posi- 
tion was untenable. Operations upon the female 
genitalia with the principal object of correcting 
a coexisting neurosis, epilepsy, or insanity, were 
unsuccessful in so many instances as to lead to 
grave doubts as to the correctness of such pro- 
cedures, and gynecologists and others began to 
remonstrate vigorously against them. 

In this earhest group of papers and accounts 
really belong a not inconsiderable number of 
others which have appeared since then, and which 
reflect, often to a marked degree, the ideas which 
one would think had been effectually dispelled 
years ago. It only shows how difficult it is to 
change opinions that have been widely accepted 
by the profession and which contain, as they usual- 
ly do, some partial truth. We are constantly 
seeing evidences of the same tendency to over- 
estimation in other fields of surgery. 

The papers of Bossi (16) (1911-12) and 
Schockaert (17) (1913) in Europe, and Hall (18) 
(1904-06) (not so extreme) in America are per- 
haps the best illustrations we may cite of recent 
papers reflecting the older views. Other papers 
are those of Moore (19) (1896), Ward (20) (1903), 
Huggins (21) (1905), Rosser (22) (1909), and 
Ballard (23) (1912). 

The behef of Bossi (16), whose reports have 
excited much comment and criticism among 
European gynecologists, is an example of the 
extreme views favoring gynecological operations 
for the cure of mentally deranged patients. He 
recognizes the usual predisposing factors in 
psychic disturbances. He states that as active 
factors we find (i) not the more serious pelvic 
diseases "as much as the infectious and toxic 
diseases, especially of the endometrium, proceed- 
ing with slow and insidious course, the parenchy- 
matous forms of functional as well as infectious 
origin. (2) The influence is so much greater 
when the infectious and toxic injuries of the en- 
dometrium are accompanied directly or indirectly 
by a stenosis of the cervix, or kinking or flexion 
of the uterus which causes a blocking back of the 
purulent and toxic secretions of the uterine cavity 
and their absorption. (3) Nervous and psychic 
disturbances often appear when in addition to 
the anatomical injuries (and often without them) 



an arrest or lessening of the menstrual function 
takes place, and as a logical consequence a dis- 
turbance of the internal ovarian secretion 
ensues." 

He says, "It must not be forgotten that the 
character, the form of the neuropsychic phenom- 
ena, caused, maintained, or accompanied by these 
pathological conditions of the uterus, stand ever 
in relation to hereditary predisposition, to the 
general condition of the organism, to rearing, 
family circumstances, and environment." 

Mayer (24) (1913) takes Bossi and his pupil 
Ortenau (25) severely to task. He says, "The 
things they speak of with such dogmatic cer- 
tainty are but unjustifiable exaggerations of 
trivial gynecological conditions." He criticizes 
Bossi's manner of making a psychopathic diagno- 
sis, it being often done for him by the laity, and 
says that the evidence Bossi gives that the pa- 
tients are cured is far from convincing. He 
thinks that suggestion is the paramount factor 
in the cures that he claims. Many of these cases 
are plainly mere hysteria, and therefore "cured" 
by almost any means. He then criticizes Bossi's 
conceptions of pelvic diseases and his assumption 
of conditions and sequences, which are neither 
proved nor assumed by modern gynecologists. 
Mayer's clear and forceful criticism would, I 
think, reflect the attitude of many of us. We 
may justly ask that such claims as Bossi makes be 
verified by the experience of scientific workers 
in the same field, and thus far they have been 
found to be signally lacking in results. 

To return, however, to our historical account, 
it was, as stated before, in the early nineties that 
w^e saw the first decided reaction from the earlier 
views. Ovariotomy as a method of correcting 
or controlling a neurosis, epilepsy, or insanity, 
was perhaps the first to go, but it was followed by 
a decided modification of ideas relative to other 
conditions in the pelvis and their relation to the 
nervous system.^ Ovariotomy not only failed 
to correct such disorders in a majority of instances 
but many were made worse, or the disorder was 
manifested in other serious ways. 

Group 2. This earUer teaching had influenced, 
to a certain degree at least, the practice of the 

' For a long time after this the ovaries were uniformly removed 
by almost all operators whenever it was deemed necessary to removfi 
the uterus. The ovary w^as also removed, with its fellow tube, when- 
ever an infection of the latter demanded its removal. Experience and 
better technical methods have taught us the feasibility of saving many 
ovaries previously sacrificed, and today these important organs are 
usually retained in the childbearing age unless (i) they are seriously 
involved by an inflammatory process or by a neoplasm which makes 
its conservation technically impossible, under which condition the op- 
posite healthy ovary is saved; and (2) unless either or both are the seat 
of malignant disease or a neoplasm which threatens the continuance of 
the disease, in which case both are removed; and (3) in radical operations 
for carcinoma of the uterus they are removed with the uterus and other 
siructures. 



INTERNATIONAL ABSTRACT OF SURGERY 



wisest and most conservative. This later period 
is marked by a broadening of professional opinion 
in regard to gynecological diseases and their 
relation to other conditions in the economy. 

At a meeting of the Obstetrical Society of 
London in 1891, Playfair (26) read a paper on the 
removal of the appendages in cases of functional 
neurosis, in which he gives as his conclusion 
that the removal of the appendages for such a 
condition is not legitimate, that in "hystero- 
epilepsy" and " hysteromania " the results of 
operation had been so unsatisfactory that it was 
a procedure of doubtful expediency and not to be 
recommended. In the discussion Spencer Wells, 
Priestly Ross (quoted by Spencer Wells), and 
several others strongly condemn the practice. 

Regis (27) (1894) points out the seriousness of 
the removal of the ovaries, and cites a case of 
insanity which followed the procedure. We 
might multiply instances of remonstrance against 
ovariotomy. 

Deale and Adams (28) (1894) made a strong 
plea for a wider view in gynecology, and Freder- 
ick (29) in 1895, in a very practical article, asked 
for a broadening of the gynecological horizon. 
Palmer (30) (1903) voices much the same opinion. 
These were earlier expressions of an attitude which 
has now become almost universal among gyne- 
cologists. Although they recognized the import- 
ance of the pelvic organs and their diseases, gyne- 
cologists saw plainly that they but shared their 
importance with other organs, and must be 
held in proper relationship. 

The neurologist took part now more frequently 
in the discussion. In 1898 Frederick Peterson, 
F. X. Dercum, and Dunn (31) all criticized 
strongly the viewpoint of the gynecologist. 
Peterson said that the field of the gynecologist 
in the domain of nervous diseases was com- 
paratively restricted and unimportant, and 
strongly protested against the prevailing ten- 
dency to enlarge the field of gynecology by un- 
justifiable and unscientific surgical intervention 
in cases of nervous and mental diseases. 

Church (32) (1904) before the Chicago Gyne- 
cological Society made a strong plea for a broader 
conception of the neuroses and insanities, and 
saw but little connection between them and the 
conditions in the pelvis. He regarded the for- 
mer as essentially cerebral diseases, not depending 
upon pelvic conditions, nor to be corrected by 
"meddlesome" operative procedures. 

Patrick (33) (1904) at the same meeting frank- 
ly and strongly criticized gynecologists. He 
stated that they are misled by their skill in re- 
moving organs and as to the effects of morbid 



anatomy, real or fancied, upon the patient. 
In his opinion they lack knowledge of the nervous 
conditions they are attempting to cure, and he 
expressed doubts as to whether a "half dozen 
members of the Chicago Gynecological Society 
would pass a fairly good examination in neuras- 
thenia, hysteria, epilepsy, and migraine." His 
attitude was typical of the neurologists of those 
days. 

Before passing on to the third group of more 
modern papers reflecting the present-day attitude 
of gynecologists, it would be well to make special 
mention of two phases of the matter under discus- 
sion which belong properly to our subject: (i) 
mental conditions following gynecological opera- 
tions, and (2) modern views in regard to opera- 
tions upon insane patients, as proved by actual 
experience in our insane asylums. 

I. Post-operative nervous sequelae are plainly 
recognized and a considerable literature is extant 
dealing with them. 

Kaiserling (34) (1906), in a study of 29 cases of 
nervousness following gynecological operations, 
states that the condition is common and not 
enough considered. Most of his patients were in 
a more or less excited state, complained of sleep- 
lessness, with other familar symptoms. He 
believes the condition should be anticipated fol- 
lowing gynecological operations, patients care- 
fully followed up, and treatment inaugurated early. 
He recommends well directed hydrotherapy 
and other general measures, and lays emphasis 
on mental therapeutics also as a necessary means 
to betterment. The earlier cases respond better 
than the late ones. About half of his cases had 
suffered from some nervous disorder before 
operation. 

Ostrom (35) (1906) faces the possibility of a 
post-operative neurosis squarely, and thinks it 
occurs only in predisposed cases. He also thinks 
that a not always to be recognized mild septic 
condition may often be the exciting cause. In 
cases that develop immediately after operation 
the prognosis is better than in those that develop 
later on. Insomnia and digestive disturbances 
following closely on operation are to be seriously 
dealt with, since they are often precursors of 
more serious nervous disturbance. 

Crouse (36) (1910) thinks that post-operative 
pain and other ill results may come from an irrita- 
tion or an involvement of the nerve plexus 
already attacked by the original disease. This 
belief is not commonly held today. 

Thibault (37) (191 2) says that a traumatic 
hysteria following a surgical operation is rare, 
though frequently it follows ordinary injury. 



SMITH: GYNECOLOGICAL AND NEUROLOGICAL CONDITIONS 



121 



2. Insanity following gynecological operations 
would seem to be a rare occurrefnce. Rohe (38) 
(1893) states that as a result of communicating 
with all of the asylums of the United States and 
Canada, he found that in all of the ten years 
prior to 1893 only 25 patients had been registered 
in all of these asylums as having become insane 
following gynecological operations. 

Kelly (39) (1906) states that there is nothing 
pecuhar in this association, since it occurs often 
after operation in general surgery and may follow 
even a simple fracture. He has seen insanity 
after abdominal operations only in 8 instances in 
something over 2,000 abdominal sections. 

Croom (40) (1899) cites a case of acute mania 
with death, following a single ovariotomy. He 
states as his opinion, however, that in women of 
sound mind and clean hereditary record such a 
thing is very rare, and that the insanity occurring 
after operation usually disappears. 

Doleris (41) (1899) cites a number of cases of 
systematized delirium, following operations upon 
the genital apparatus, occurring in "neurasthenic 
subjects" without nervous hereditary disorder. 

Mauclaire (42) (1904) regards the post-opera- 
tive psychoses as rare, substantiating his views 
by quoting Werth as observing 6 cases in 228 
gynecological operations, and Segond as having 
4 cases in 642 operations. These statistics would 
apparently apply to the insanities and not to the 
simpler neuroses, which we are all aware are more 
frequent. 

Picque (43) (1906) distinguishes two forms of 
post-operative insanity — those of septic and 
toxic origin, and those occurring in old people, due 
to brain changes, or those mentally weak in 
whom there exists an intense fear and dread of 
operation. 

Hammond (44) (1906) says: "I don't beHeve it 
possible for any psychosis to develop after any 
operation on the pelvic organs in a healthy brain. 
.... The principal cause is a congenitally 

defective brain The psychological 

causes are by no means unimportant — fear 
of death from operation, disappointment at not 
being able to bear children, and the consequent 
curbing of the maternal instinct, the fear of 
loss of the husband's love, the fear of becoming 
cold and indifferent to the husband, and the 
fear of acquired masculinity — all contribute, 
in a brain predisposed to insanity, a great in- 
fluence in developing a psychosis." Physical 
causes and surgical shock also contribute. 

Picque and Briaud (45) (1903) state that pelvic 
operations do not predispose to psychoses more 
than other operations. 



The papers of Manton (46), Broun (47), 
Picque (43 and 45), Taussig (48) (191 2), and 
Regis (49) (1904-05) all reflect a large and 
carefully judged experience upon insane patients. 
They all concur in the idea that insane patients 
should be operated upon for coexisting, frank and 
outspoken gynecological diseases as one would 
operate upon the same patients if they were 
sane. They believe that an improvement in the 
physical condition may result in mental improve- 
ment, but that we cannot expect to cure such 
patients by operating. Manton (1908) states 
that he has never seen any insane patients recover 
purely through a surgical procedure. 

The summing up of Broun (47) (1908), who 
has been assisted by alienists in the psychopathic 
diagnosis, is worthy of quotation. In what form 
of insanity may the surgeon benefit his patients? 

1. "I think alienists would consider, in the 
first place, that small group of disorders in which 
operation aims to reach directly the exciting 
cause; namely, the psychoses with operable brain 
tumors, traumatic lesions of the skull, acute hal- 
lucinoses with middle ear or mastoid disease, the 
deliria in connection with local infections, and, 
perhaps, some of the psychoses accompanying 
thyroidism. 

2. "Owing to the evident complexity of the 
etiology which exists, even in the best circum- 
scribed symptomatic group, it is clear that in the 
general estimation of the value of surgical inter- 
ference it must be regarded as a procedure rank- 
ing with our other therapeutic measures which 
aim to get the patient as quickly as possible into 
a condition of bodily comfort and physical vigor. 

3. "Manic-depressive insanity is regarded 
rather as a disorder arising on a constitutional 
basis and expressing itself in one or more attacks 
liable to be elicited by a great variety of causes, 
among which states of physical ill health are very 
important. In cases where the surgeon can 
relieve the condition which is wearing on the 
patient, causing worry, pain, or loss of sleep, 
good results may be expected to follow, and some- 
times recurrence of attacks prevented. 

4. "In the alcoholic group the psychoses often 
develop in connection with some physical disease, 
especially infectious disorders, and special men- 
tion has been made by Kraepelin, Mott, and 
others of infections in the genital tract, particular- 
ly in women, as an important element in causing 
the outbreak and continuance of the psychosis. 

5. "In the infective exhaustive group good 
results can be expected wherever foci of infection 
can be attacked and removed, or where any ex- 
hausting influence can be checked. 



122 



INTERNATIONAL ABSTRACT OF SURGERY 



6. "In the large group of dementia praecox, 
little in the way of permanent improvement can 
be expected, as it is here probably that certain 
deeply rooted inherent traits are working with 
various mental causes to bring about a gradual 
disintegration of the personality." 

With a subject so complex and the neuroses 
still but partially understood, even by the 
neurologist who devotes a large share of his 
time and attention to them, one would hardly 
expect a perfect unanimity of opinion among 
gynecologists as to their relationship to gyneco- 
logical conditions, but years of experience in 
cHnical work and a knowledge of what has tran- 
spired in the many years of gynecological history 
has brought gynecologists very close together. 
We find that they have come a long way toward 
the viewpoint of the neurologist; namely, that 
the neuroses and psychoses are essentially mental 
in character. They exhibit a marked respect 
for the mental state of patients who apply to 
them for gynecological aid, and they consult 
frequently with the neurologist for whose opinion 
they have increased respect. 

The gynecologist believes that a neurosis has 
commonly nothing to do with conditions in the 
pelvis, nor any other physical condition. He 
believes that septic conditions in the pelvis, or 
what is more common, those that are so clearly 
and frankly outspoken as to necessarily cause 
pain and discomfort, may sometimes act as so 
powerful a contributing cause as to make their 
removal an essential element in the restoration 
of the patient to a state of equilibrium. He 
believes that these same pelvic lesions at 
other times, when corrected by operative means, 
may be helpful in arriving at the same re- 
sults by putting such patients in better physi- 
cal condition. He thinks much the same 
of other physical conditions. He does not 
operate for trivial or imaginary lesions with the 
expectation of curing an abnormal mental state. 
The days of "endometritis," "cervical stenosis," 
"kinks and flexures," and of "cystic ovaries" are 
gone. He recognizes clearly the importance of 
the ovaries in the preservation of nervous equilib- 
rium, and his attitude toward them is one of 
marked conservation. 

With a full appreciation of what it may mean 
to his patient, he preserves or removes the various 
pelvic organs with their functions only after a 
careful consideration of the age, social condition, 
the demands for the preservation of the child- 
bearing function, the marriage relation, and men- 
struation, as well as any other matter that may 
have a bearing upon her condition of mind, 



whenever the pathological condition gives him 
any choice. A pelvic operation is seldom a 
matter of mere mechanics. By carefully judging 
the many phases which a gynecological problem 
presents, he strives to conserve or attain a sat- 
isfactory mental state. 

I do not know that we could select two better 
papers than those of Reynolds (50) (1910), and 
Graves (51) (1913) to illustrate these ideas. 
They are practical papers, reflecting thought 
and experience, and it is safe to say that neurolo- 
gists would find little room for disagreement with 
them. 

Group 3. To this group belong a number of 
neurological papers which deal with the progress 
of neurology and the conceptions of the neurolo- 
gist, and a very few papers by gynecologists 
in whom the work of the neurologist is clearly 
recognized and upon whose ideas and writings 
the work of the latter is plainly stamped. 

During these years the neurologist has not 
been idle. Adhering persistently to the principle 
that the neuroses were essentially mental in 
nature, he has delved deep into the workings of 
the human mind, and has laboriously studied its 
phenomena. He is today more than ever satis- 
fied that the truth lies in this direction. In 
this modern study we hear little from the neurolo- 
gist concerning pelvic lesions or any other surgi- 
cal lesions as having any marked bearing upon 
the mental condition of the patient, the relation- 
ship being at best it would seem but an indirect 
one. 

In the medical sense, as Jones (52) (1913) 
says, "the neuroses are not diseases at all but 
only in the social sense. A medical disease is a 
product of an interaction between a given individ- 
ual and an injurious, non-human environment, 
whether the latter be a physical trauma or an 
invasion of micro-organisms. On the other 
hand, a social disease is a product of interaction 
between an individual and a certain human en- 
vironment. Put a little figuratively, it may be 
said that the neuroses are the result of a conflict 
between an individual and society, whereas other 
diseases are the result of a conflict between an 
individual and nature. This fundamental dis- 
tinction is often not grasped by members of the 
medical profession, who commonly regard all 
diseases from the one standpoint, and the failure 
to grasp it is an important reason why the pathol- 
ogy of the neuroses has in the past been investi- 
gated with signal lack of success." 

Whereas practical neurologists, most of them 
at least, recognize the necessity of looking after 
the physical condition of the patient as being of 



SMITH: GYNECOLOGICAL AND NEUROLOGICAL CONDITIONS 



123 



importance in the betterment or cure which they 
hope to obtain, they are turning their attention 
more than ever before to mental therapeutics. 

There have arisen a number of schools of men- 
tal therapeutics, based upon the various truths 
obtained: First (quoting from Jones), those 
having as a basis, suggestion; second, reassocia- 
tion; third, psychanalysis. 

The French have apparently busied themselves 
more with the various methods in which sugges- 
tion was the main form of dependence than other 
nations. 

Dubois (53) (1909), whose memorable work 
made such a stir in this country several years ago, 
denying the permanent good results of bhnd 
suggestion, appeals to the reason of the patient 
to overcome his abnormal mental state, with the 
fundamental idea that under the guidance of the 
physician the normal mental activities may be 
thus controlled. It is assumed that the patient 
is able to reason himself out of his abnormal 
mental state, and does not sufficiently recognize 
that the disturbance is an emotional one fre- 
quently beyond his control. 

One cannot speak of modern neurology without 
referring to the work of Freud (54), and it would 
seem well that every gynecologist (and for that 
matter every practitioner of medicine) should 
read Freud's writings. It would not be to our 
purpose in this review to give even a short ab- 
stract of his ideas. One cannot but feel that 
Freud has uncovered many important and far- 
reaching truths. One has a feeling, however, 
if he may judge by his experience in other matters, 
that much needs to be modified, that the connec- 
tion is often less direct than he has assumed, that 
less general sweeping statements should have 
been made, and that the sexual idea fails to 
satisfactorily explain many of the abnormal 
mental symptoms with which he comes in con- 
tact. 

Freud has seemed to me to have emphasized, 
however, the essentially emotional nature of the 
neuroses. That it is the emotions of the patient 
that are primarily affected, which lead to the 
abnormal manner of thinking and the vast num- 
ber of physical disturbances of function which 
have sometimes been erroneously ascribed direct- 
ly to organic disease of the organs from which the 
symptoms arise. 

Findley's (55) paper (1909) clearly reflects 
the influence of Dubois. He urges the necessity 
of treating gynecological patients by mental 
therapeutics when they present a neurosis. 

In conclusion, it would be well to cite at some 
length the work of Walthard (56), whose several 



papers form a distinctly valuable contribution 
to our subject. Walthard worked with Paul 
Dubois (Berne) and his pupil, L. Schnyder (Berne), 
for ten years. His paper " Psychoneurose and 
Gynaecologie" (191 2) I am giving almost in its 
entirety for it is difficult to abbreviate it much and 
maintain its clearness. 

He says the various functions of the female 
genitaha are not dependent upon the presence of 
the cerebrum. They proceed automatically in 
animals without a cerebrum, and in those that 
have been decerebrated, as do the functions 
of the circulatory, digestive, respiratory, and 
urinary organs. They proceed with machine- 
like regularity, unconsciously and automatically. 
In women with complete transverse lesions of 
the spinal cord the same may be observed. Their 
secretions are normal, they menstruate, conceive, 
carry the child to term, and go through normal 
labor. 

Mental conceptions (vorstellungen) , however, 
have their effect normally upon the visceral 
organs, among which may be reckoned the genita- 
lia. For example, libidinous ideas lead to in- 
creased secretion of the bartholinian glands. 
Regularity of function is influenced also by the 
sensitiveness or irritability (erregbarkeit) of 
the central nervous system of the individual. 
This sensitiveness may be increased by the 
various poisons, such as strychnine, caffeine, 
and camphor, or by the internal secretions such 
as that of the thyroid. Hunger has the same 
effect, as does also strenuous physical or intellec- 
tual work. 

Also in a similar manner the abnormal mental 
processes of the psychoneurotic individual in- 
creases the sensitiveness. This manifests itself 
by such psychic symptoms as fear, anxiety, in- 
ward unrest, a tendency to depression, and the 
existence of physical symptoms in the form of 
functional disturbances of various organs. The 
influence of the mental processes upon the fe- 
male genitalia is then twofold — the direct 
influence of conceptions working indirectly 
through the increased irritability of the central 
nervous system. To illustrate — neurotic women 
with strong erotic ideas have a constantly in- 
creased flow from the bartholinian glands, and 
this does not subside until such erotic ideas are 
corrected. Anticipation of pain, antipathy for 
coitus or the husband, and fear of pregnancy, 
even with perfectly healthy genitaha, may lead 
to vaginismus. A spasm may be excited by the 
mere thought of anything entering the vagina, as, 
for instance, the cUcking of instruments before 
examination. Vaginismus then is not a sub- 



124 



INTERNATIONAL ABSTRACT OF SURGERY 



cortical reflex, but a warding off movement 
induced by a mental conception. 

The body functions are, as said, influenced 
indirectly and very greatly by the increased 
irritability or sensitiveness of the central nervous 
system, brought about by the abnormal mental 
processes of the psychoneurotic patient. The 
direct influence is the conceived idea. Now, 
every individual entertains either with desire or 
aversion the ideas which touch his interests. 
These ideas lead to corresponding acts. Whether 
desirable or undesirable, many conceived ideas 
cannot end in corresponding action. When such 
ideas cannot be shut out from further considera- 
tion, their continued appraisement leads to this 
increased irritability of the central nervous sys- 
tem. With the neurotic such ideas become fixed 
— there is an inability to cease entertaining them, 
and there is a tendency to exaggerate them. 
The increased irritability found in such individ- 
uals affects the function of many of the organs, 
the sex organs among the others. The irri- 
tability is increased to such a degree that they 
note sensations which escape the healthier indi- 
vidual. 

In the female genitaha we find that this takes 
three forms: an increase of secretions, an in- 
crease in the muscular activities, or an increase 
in the conscious sensations. The secretions of 
the uterus, for example, are increased, unasso- 
ciated with any inflammatory process (simple 
leucorrhoea). The influence of the psychic pro- 
cesses upon the menses is well known. They lead 
often to the early appearance or a sudden inter- 
ruption of the menses, their delay or complete 
non-appearance. Small quantities of blood may 
appear between periods. These are but examples. 
We may have abortion or premature labor, and 
marked disturbances in labor may be the result 
of this increased excitability. 

In greater degree are the conscious sensations 
arising from the female genitalia through a 
psychoneurosis under such conditions. These 
conscious sensations manifest themselves in 
the outer genitalia by itching and burning. 
During menstruation or between periods pa- 
tients complain of a feeling of bearing down or 
falling of the genitals. Also they have various 
pains, variously described, which may give rise 
to the belief that actual disease is present. In 
dysmenorrhoea this is frequently a prominent 
factor. Walthard goes into these symptoms at 
greater length. He warns against assuming 
such disturbances to be neurotic manifestations 
unless the mental processes are shown to be of 
such a character and all other causes for a func- 



tional disturbance may be excluded. He says that 
such patients often present a normal demeanor 
and that it sometimes takes weeks or even 
months to uncover their real mental condition. 

Psychoneurotic symptoms of the different 
organs do not disturb all patients aHke. As 
with the psychic processes of the healthy in- 
dividual the great majority of whose conceptions 
are passed by, so with the psychoneurotic, the 
majority of such functional disturbances are un- 
noticed. Only those symptoms which touch the 
interest of the patient (that is, which the patient 
holds as symptoms of disease) are entertained 
with a sense of aversion, and provoke a feeling 
of uneasiness and anxiety, and at the same time 
send her to the physician for relief. All other 
symptoms are passed by unnoticed and can only 
be brought out in the examination. Such psy- 
choneurotic symptoms can display themselves 
in every organ of the body, and therein lies the 
reason why one seeks the internist, the other the 
neurologist, and the third the gynecologist. 

What have diseases of the pelvic organs to do 
with the manifestation of psychic symptoms? 
Walthard states that no one today believes that 
through any physiological or pathological pro- 
cesses any permanent real change in the thinking 
processes of the individual from the normal to 
the abnormal can take place. Even extremists 
like Bossi admit a certain predisposition to a 
psychoneurosis. 

The influence of any disease of the genital 
organs on the mental process is principally a 
psychic one and not, as has been assumed, a 
physical one. The connection between the two 
is the increased affectibihty {gesteigerte affec- 
tivitaet) . Those who examine many women will 
find that scarcely in ten per cent of the neurotic 
patients that come to him is there any gross 
pathological lesion. Where lesions are found, 
they are usually of lesser degree, such as an 
erosion, a chronic endometritis, a movable, 
retroverted uterus, or a prolapsed ovary. On the 
other hand, with rare exceptions, there are lack- 
ing with such patients gynecological diseases 
which produce haemorrhage, loss of flesh, and 
cachexia. It happens frequently that patients 
with severe neuroses are quite unaware of serious 
pathological processes in the pelvis, their atten- 
tion being concentrated upon other things, as, for 
example, in melancholia and in hypochondriacal 
and hysterical conditions. On the other hand, 
if a disturbance of the genital function touches 
the interest of the patient, it will at once be 
noticed in its sHghtest departure from the 
normal. The increased " affectibility " of such 



SMITH: GYNECOLOGICAL AND NEUROLOGICAL CONDITIONS 



125 



patients makes their genital functions a matter 
of lasting fixation and consideration. We see 
such disturbances after diminution, delay, or 
failure of the menses, with its fear of pregnancy. 
We also see it when menstruation occurs where 
pregnancy is desired, or at the climacteric, with 
its fear of the disappearance of youth and for 
the infirmities of old age. Just so in the matter 
of sex relations. Only when abstinence or 
abnormal coitus awakens the ideas of deceit, 
suspicion, or remorse, which becomes fixed and 
overestimated, do psychoneurotic symptoms ap- 
pear. If the anomalies of the genital function 
call forth conceptions that they are "geni tally 
diseased" or physically sick, so it is again that 
the increased afectivitaet leads to fixation and 
overestimation, whether the disease is real or 
only functional in nature. When such ideas 
can be corrected, the particular disturbance disap- 
pears, but not the fundamental abnormal man- 
ner of thinking of the individual. This all 
shows that the relation between the disturbances 
of the genital tract and the mental disturbances 
are in the main psychic. 

Material disease of the genitals themselves, 
attended with acute loss of blood or with intoxi- 
cation, may, of course, bring about psychic dis- 
turbances in those so predisposed, disturbances 
which would not have happened to them in 
health. They are like the other influences of 
every-day life — disturbances of temper, sup- 
pressed sexual feeling, acute infectious diseases, 
and intoxications — and are to be regarded as 
opportunities which inaugurate the psychic 
symptoms in those so predisposed. The pri- 
mary predisposing factor is the psychoneurosis 
resulting from birth and breeding. 

Walthard criticizes the attitude of Bossi and 
others who hold the existence of a direct connec- 
tion between the condition in the pelvis and the 
psychosis. The good results that occasionally 
follow in such patients in operations upon the 
genitals for harmless lesions are to be explained 
by suggestion, but such cures can by no means 
be relied upon. The personality of the surgeon, 
and the suggestion that comes to the patient 
through him, all go to make up the therapeutic 
result. The patient still remains, however, es- 
sentially a psychoneurotic, and such patients 
he says should be treated by psychotherapy. 
These ideas he says are much in accord with 
similar ones of the alienist, the neurologist, or 
the internist. He urges for the gynecologist 
the study of psychic neuroses from the stand- 
point of the neurologist. 

In Walthard's second article, appearing about 



the same time, he gives a most clear and concise 
description of the genital reflexes and their 
physiology. He divides them into two groups — 
the subcortical and the psychic — explains each 
and their correlation. From their behavior 
under normal conditions he passes to that under 
pathological conditions. He describes their ac- 
tion as affected by organic nervous diseases and 
the same under the influence of the neuroses. He 
shows how the pelvic functions are affected by 
the influence of the abnormal mental processes, 
and then goes in some detail into the mental 
therapeutics which he has evidently obtained 
in his association with Dubois. The paper is 
an elaboration of many matters touched upon 
in the article already reviewed. Its study in 
detail is well worth while. 

The gynecologist will look forward with much 
interest to the future work of the neurologist 
and those scientific workers who are endeavoring 
to learn more of the human mind, for the neurotic 
patient is to him a daily source of interest and 
perplexity. I understand that the study of 
comparative psychology and animal behavior 
promises to be of material aid in this future work. 



BIBLIOGRAPHY 

1. Storer, H. B. Obstinate erotomania. Am. J. 

Obst., N. Y., 1868, i, 423. 

2. Emmett, T. a. Lacerations of the cervix uteri as a 

frequent and imrecognized cause of disease. Am. 
J. Obst., N. Y., 1874, vii, 442. 

3. Ibid. Etiology of uterine flexures with the prop)er 

mode of treatment indicated. Tr. Am. Gynec. 
Soc, N. Y., 1876, i, 99. 

4. Skene, A. J. C. Cicatrices of the cervix uteri and 

vagina. Tr. Am. Gynec. Soc, N. Y., 1876, i, 91. 

5. Engelmann. Tr. Am. Gynec. Soc, 1877, ii, 483. 

6. Fallen, M. A. Some suggestions with regard to the 

insanities of females. Am. J. Obst., N. Y., 1877, 
x, 206. 

7. Edis, a. W. The influence of uterine disorders in the 

production of numerous sympathetic disturbances 
of the general health and affections of special organs. 
Am. J. Obst., N. Y., 1881, xiv, 926. 

8. BiGELOW, H. R. Nerve pain in gynecology and the 

rest treatment. Am. J. Obst., N. Y., 1881, xiv, 
619. 

9. Skene, A. J. C. The relation of the ovaries to the 

brain and nervous system. Am. J. Obst., N. Y., 
1881, xiv, 54. 

10. Battey, Robert. Battey's operation — removal 

of ovaries. Am. J. Obst., N. Y., 1877, x, 711. 

11. Ibid. Reported by Yandell and McClellan. Am. 

J. Obst., N. Y., 1876, ix, 140. 

12. Carstens, J. H. Three cases of Battey's operation. 

Am. J. Obst., N. Y., 1883, xvi, 266. 

13. Johnson, Jos. Taber. Battey's operation. Am. J. 

Obst., N. Y., 1883, xvi, 305. 

14. Lee. Am. J. Obst., N. Y., 1887, xx, 732. 

15. Byford. Am. J. Obst., N. Y., 1888, xxi, 1206. 



126 



INTERNATIONAL ABSTRACT OF SURGERY 



i6. Bossi, L. M. Neuropsychopathies d'originie genital. 42. 

Ann. de gynec. at d'obst. , Par. ,1911, viii, 743 . 
Ibid. Eierstocks-Uteruskrankheiten und Psycho- 

pathien. Zentralbl. f. Gynaek., 1912, xxxvi, 1213. 43. 
Ibid. Meine Ansichten ueber der reflektorischen 

Psychopathien, etc. Wien. klin. Wchnschr., 1912, 44. 

No. 47, 1868. 

17. ScHOCKAERT, R. Psychopathics d'origine genitale. 

Rev. mens, de gynec. d'obst. et de pediat., Par., 45. 
1913, viii, 373. 

18. Hall, E. A. Deductions from the study of pelvic 46. 

disease in the female insane. Brit. Gynasc. J., 

Lond., 1904, XX, 120. 
Ibid. Psychoses associated with pelvic disease. 

Am. J. Surg. & Gynec, 1904, xviii, 86. 
Ibid. Additional experience in the treatment of 

pelvic disease, associated with psychoses. Canada 

Lancet, Toronto, 1905, xxxix, 597. 
Ibid. An inquiry into the relationship between pelvic 

disease in the female and abnormal psychic action. 

W. Canada M. J., 1907, i, 144. 

19. Moore, Jas. E. Nymphomania cured by hysterec- 

tomy. Am. J. Obst., N. Y., 1896, xxxiv, 554. 

20. Ward, E. B. Reflex neuroses in women. Med. Age, 

Detroit, 1903, xxi, 241. 47. 

21. HuGGiNS, B. R. Insanity precipitated by pelvic 

disease in the female. Ann. Gynec. & Pediat., 
1905, xviii, 331. 

22. RossER, C. M. Surgical intervention in the treat- 

ment of neurasthenic states. Tr. South. Surg. & 
Gynec. Ass., Phila., 1909, xxi, 453. 

23. Ballard, C. N. Nervous phenomena as sequelae of 

changes in the pelvic viscera. Am. J. Obst., 
N. Y., 1912, Ixv, 451. 

24. Mayer, A. Die lehre Bossis und die Gynaekologie. 

Wien. klin. Wchnschr., 19 13, xxvi, 499. 

25. Ortenau. Sieben Faelle von psychischer Erkran- 

kung nach gynaekologischer Behandlung geheilt. 
Muenchen. med. Wchnschr., 1912, No. 44, 2388. 

26. Playfair. Am. J. Obst., N. Y., 1891, xxiv, 635. 48. 

27. Regis, E. Am. J. Obst., N. Y., 1894, xxix, 571. 

28. Deale and Adams. Neurasthenia in young women. 

Am. J. Obst., N. Y., 1894, xxix, 190. 49. 

29. Frederick, C. C. Neurasthenia accompanying and 

simulating pelvic disease. Am. J. Obst., N. Y., 50. 
189s, xxxii, 829. 

30. Palmer, C. D. The relation and corelation of 

gynecological and nervous affections. Am. J. 51. 
Obst., N. Y., 1903, xlvii, 755. 

31. Peterson, Fred, Dercum, F. X., and Dunn, B. S. 

Am. J. Obst., N. Y., 1898, xxxviii, 896. 52. 

32. Church, Archibald. Am. J. Obst., N. Y., 1904, 1, 

537. 53. 

SS. Patrick, Hugh T. Am. J. Obst., N. Y., 1904, 1, 543. 

34. Kaiserling, Otto. Ueber Nervositaet im Anschluss 54. 

an gynaekologische Operationen. Berl. klin. 
Wchnschr., 1906, xliii, 419. 

35. OsTROM, H. I. The psychoses following gynecologi- 55. 

cal operations. Hahneman. Month., 1906, xli, 
161. 

36. Crouse, H. W. Post-operative neuroses of pelvic 56. 

origin. Am. J. Obst., N. Y., 1910, Ixii, 622. 

37. Thibault. Hystero traumatisme d'origine opera- 

toire. Marseille med., 1912, iv, 52. 

38. RoHE, Geo. H. N. Y., M. J., 1893, October. 

39. Kelly, H. A. Operative gynecology, 1906, ii, 641. 

40. Croom, J. H. Am. J. Obst., N. Y., 1899, xl, 124. 

41. Doleris. Am. J. Obst., N. Y., 1899, xxxix, 400. 



Mauclaire. Neurasthenic et psychoses genitales 
ante et post-operatories chez la femme. Rev. 
gen. de clin. et de therap., Par., 1904, xviii, 609. 

PicQUE. Quoted by Broun. Am. J. M. Sc, 1906, 
cxxxi, 264. 

Hammond, G. M. Insanity as a result of hysterec- 
tomy and oophorectomy. J. Am. M. Ass., 1906, 
xlvi, 713. 

PiCQUE and Briaud. Quoted by Hammond. J. 
Am. M. Ass., 1906, xlvi, 714. 

M ANTON, W. P. Experiences in abdominal surgery 
on the insane. Am. J. Obst., N. Y., 1892, xxvi, 791. 

Ibid. The relation of visceral disorders to the de- 
lusions of the insane. Am. J. Obst., N. Y., 1896, 
xxxiv, 806. 

Ibid. The frequency of pelvic disorders in insane 
women. Am. J. Obst., N. Y., 1899, xxxix, 54 

Ibid. Some lessons learned during twelve years 
experience in abdominopelvic surgery among 
insane women. Tr. Am. Gynec. Soc, 1901, xxvi, 383 

Ibid. Discussion. Tr. Am. Gynec. Soc, 1903 
xxviii, 77. 

Ibid. Discussion. Tr. Am. Gynec Soc, 1908 
xxxiii, 180. 

Broun, Le Roy. Some conclusions after operating 
for two years on the pelvic diseases of insane women. 
Am. J. Obst., N. Y., 1905, li, 208. 

Ibid. A preliminary report of the gynecological 
surgery in the Manhattan State Hospital West. 
Proc Am. Med. Psychol. Ass., Baltimore, 1905, 
xii, 263. 

Ibid. Operations for relief of pelvic diseases in 
insane women. Am. J. M. Sc, 1906, cxxxi, 255. 

Ibid. Second report on operations for relief of pelvic 
diseases of insane women, including 411 patients; 
a study of the character of operations appearing 
to give best results; also the character of the in- 
sanity receiving the greatest benefit. Tr. Am. 
Gynec. Soc, 1908, xxxiii, 165. 

Taussig, F. J. Gynecological disease in the insane, 
and its relationship to the various forms of psy- 
choses. J. Am. M. Ass., 1912, lix, 713. 

Regis, E. Gynecologic ct psychoses. J. de med. 
de Bordeaux, 1904, xxxiv, 941; 1905, xxxv, 5. 

Reynolds, Edw. Gynecological operations on 
neurasthenics; advantages, disadvantages, selec- 
tion of cases. Boston M. & S. J., 1910, clxiii, 113. 

Graves, W. P. Relationship between gynecological 
and neurological diseases. Boston M. & S. J., 
1913, clxix, 557. 

Jones. Modern treatment of nervous disorders. 
White and Jeliffe. Vol. i, p. 321. 

Dubois, Paul. The psychic treatment of nervous 
disorders, 1909. 

Freud, Prof. Sigmund. Three contributions to the 
sexual theory, 1910. The interpretation of dreams, 
1913. The psychopathology of every-day life. 

FiNDLEY, Palmer. Psychotherapy in diseases of 
women. Am. Gynec. & Pediat., Boston, 1909, 
xxii, 12. 

Walthard, M. Die psychogene aetiologie und die 
psychotherapie des vaginismus. Muenchen. med. 
Wchnschr., 1909, Ivi, 1898. 

Ibid. Der Einfluss des nervensystems auf die Func- 
tionen der weiblichen Genitalien. Prakt. Ergebn. 
d Geburtsh. u. Gynaek., 1910, ii, 245. 

Ibid. Psychoneurose und Gynaekologie. Monatschr. 
f. Geburtsh. u- Gvnaek., Berl., 191 2, p. 36. 



ABSTRACTS OF CURRENT LITERATURE 



GENERAL SURGERY 



SURGICAL TECHNIQUE 



OPERATIVE SURGERY AND TECHNIQUE 

Stewart, H. S.: Wound Dressings. Am. J. ObsL, 
N. Y., 1916, Ixxiii, 284. 

After discussing the subject the author sum- 
marizes as follows: 

1. Dried ligatures, drains, pads, etc., do not ad- 
here to wounds. 

2. The non-adhesion allows of unlimited wound 
inspection and fosters healing. 

3. The best way to treat wounds may be easily 
discovered by experimentation with boils. 

4. If one wishes to use iodine, calomel 1:1000 
should be added to the tincture, and 5i of this 
mixture and an equal part of gylcerine to 5i of 
water used. This will prevent tanning and will 
permit penetration of the tissues. 

If the patient has iodine idiosyncrasy, or if for 
any reason the wound does not do well, the use of 
iodine should be abandoned at once and 1:5000 
nitrate of silver, or its equivalent, substituted. 

There is just as much difference in the wound heal- 
ing of two different patients as there is in two 
pneumonias, two typhoids, or two gouts. Routine 
treatment may be successful, but frequently it is 
not; therefore, if the patient is to use H2O2 plus 
iodine, the results to be anticipated are either good 
or deplorable; there seems to be no middle course. 

C. H. Davis. 

Ck>hn, I.: Acute Dilatation of the Stomach Com- 
plicating Operations on the Extremities. 

Ann. Surg., Phila., 1916, Ixiii, 263. 

After a very careful review of all the available 
literature on the subject the author summarizes the 
experimental, pathological, and theoretical work as 
follows : 

1. The nerve supply of the stomach and intes- 
tines is intimately connected with the causation of 
acute dilatation of the stomach. 

2. The inhibitory nerve supply of the stomach 
and intestine is identical — the splanchnic. 

3. Strong impulses applied to the splanchnics 
cause a cessation of peristalsis. 

4. Whether these impulses be the result of 
trauma, infection, or what not, the effect here, as in 
shock, is the same — an acute dilatation of the 



stomach, with or without dilatation of the duode- 
num and, in some instances, part of the jejunum. 

5. Obstruction by the mesentery and its vessels 
is not present in over 50 per cent of cases. 

6. For the above reasons it seems most probable 
that we are dealing with a disturbance of innerva- 
tion, rather than a mechanical obstruction due to 
compression by the mesentery and its vessels. 

In 1902, Conner was able to collect 102 cases of 
acute dilatation of the stomach, 5 of which followed 
operations on the extremities. The author has 
been able to collect records of 9 cases. To these 
he adds 4 cases as the result of a personal communi- 
cation with about 125 American surgeons, and one 
case of his own. The case reported by the author 
followed an operation for osteomyelitis of the femur. 
The symptoms did not develop until four and a half 
days after operation and the patient lived eleven 
days after its onset. As much as seven pints of 
fluid was siphoned off at one time. At autopsy 
the stomach was found enormously dilated and the 
intestines were somewhat distended, but there was 
no evidence of an inflammatory process, and no 
pathology which would throw any light upon the 
etiology of the disease. Gatewood. 

Kane, E. O. : Use of Fluoroscope to Avoid Leaving 
Gauze Pads and Sponges in the Abdomen. 

Am. Med., 1916, xi, 55. 

An easy method of obviating the common diffi- 
culty in accounting for gauze pads and sponges after 
operations, which answers admirably, is as follows: 

All gauze pads and sponges are stamped at one 
comer with a metal button. Under the fluoroscope, 
with a powerful X-ray machine, this button can be 
clearly seen at any depth of the abdominal or pelvic 
cavity, no matter how obese the subject. When 
there is any dispute or question, after counting 
the sponges, as to whether or not one has been over- 
looked and lost within the abdomen, the patient is 
run into the adjoining X-ray room. Here, by a 
glance through the fluoroscope or by taking a 
skiagraph, the question is quickly settled. 

An ordinary glove-maker's foot or hand button- 
stamper and the larger sizes of glove snap-buttons 
can be procured at a very small expenditure and 
nothing more is necessary. Eow.AiU) L. Cornell. 



127 



128 



INTERNATIONAL ABSTRACT OF SURGERY 



ASEPTIC AND ANTISEPTIC SURGERY 

Rogers, A. : Toluol as a Storing Fluid for Catgut. 

Ann. Surg., Phila., 1916, Ixiii, 312. 

Considerable difficulty has been experienced in 
finding a satisfactory storing medium for catgut 
prepared by the Kroenig method whereby the suture 
material, submerged in cumol, is subjected to a high 
degree of heat. Owing to its slow evaporation, 
cumol is not desirable as a preservative. Chloro- 
form has been used, but its susceptibility to deterior- 
ation from age, sunlight, and heat makes it unde- 
sirable. 

Toluol, CeHsHs, is a very stable compound, is 
very volatile, and has a pleasing odor. It will not 
hold water in solution, and as a powerful solvent of 
fats and fatty acids is of great value in removing 
these irritating substances found in the raw catgut. 
Toluol is not irritating to tissues when applied 
superficially or deeply. It also possesses a certain 
amount of germicidal power and seems to the author 
to be much superior to any other preserving fluid 
used for storing cumol catgut. Gatewood. 

ANESTHETICS 

Coburn, R. G. : Notes on Nitrous Oxide Adminis- 
tration. /. Am. M. Ass., 1916, Ixvi, 799. 

Even with the accumulated knowledge gained 
from several years' experience in the prolonged 
administration of nitrous oxide (and oxygen), 
there is still quite a tendency shown by some to 
disregard essential elements of safety, especially 
when nitrous oxide, administered with normal 
oxygenation, does not furnish a sufficient depth of 
anaesthesia. Increasing the percentage and, therefore, 
the amount of nitrous oxide inhaled, of course, 
deepens the anaesthesia and this is often a great 
desideratum; but the increase in the depth of 
anaesthesia thus gained simultaneously decreases 
the oxygenation and herein lurks the danger. Most 
patients can tolerate decreased oxygenation for a 
short time and when from experience with this class 
of patients the anaesthetist becomes emboldened 
to minimize the danger arising from subnormal 
oxygenation, sooner or later a patient who cannot 
tolerate even temporarily a decreased oxygenation 
reaches the service of such an anaesthetist and serious 
results sometimes follow very quickly. It cannot 
be stated too frequently or too emphatically that 
with an anaesthetic cyanosis is a danger signal that 
should not be disregarded. 

The addition of a small amount of ether to nitrous 
oxide not only increases the depth of anaesthesia, 
but acts as a stimulant as well, and in this particular 
enhances the safety of nitrous oxide. To insist 
that either straight nitrous oxide or straight ether 
shall be administered is to limit greatly the use of 
this most bland anaesthetic and, at the same time, 
create such a general atmosphere that when it is 
used, if with normal oxygenation it does not furnish 
sufficient depth of anaesthesia, the nitrous oxide 



is increased by decreasing the oxygen, thus in a 
greater or less degree endangering the patient. 

Proper nitrous oxide administration requires more 
attention to technique than the other general anaes- 
thetics. Rebreathing through a long tube un- 
necessarily consumes the patient's energy at a time 
when it should be conserved and causes an unduly 
rapid accumulation of carbon dioxide on account of 
the space in the mask and long tube preventing an 
immediate and thorough mixture of the expirations 
with the contents of the bag. Rebreathing cer- 
tainly enhances the safety of nitrous oxide, but 
whenever rebreathing is used, the bag should be 
close to the patient's face. 

Nitrous oxide causes more swelling of the soft 
tissues of the upper respiratory tract than the other 
anaesthetics and at the same time increases the 
volume of respiration per unit of time; in its ad- 
ministration, therefore, it is very important to 
keep the respiratory passages open. 

Preliminary medication in nitrous oxide adminis- 
tration is a very important matter. Morphine 
tends to allay pre-operative fear and renders the 
induction smoother. 

The use of a local anaesthetic to block off the trau- 
matized areas is not nearly so general as its merit 
warrants. There is no question but that this pro- 
cedure when properly carried out prevents shock and 
permits the use of a lighter general anaesthesia, and 
this is especially shown when nitrous oxide is 
administered. Edward L. Cornell. 

MacNider, W. D. : The Inhibition of the Toxicity 
of Anaesthetics for the Nephropathic Kidney. 

/. Pharmacol. SaExper. Therap., 1916, viii, 116. 

The experimental data which forms the basis of 
this study has been obtained from observations 
upon 28 dogs. The animals were rendered acutely 
nephropathic by the administration of uranium 
nitrate subcutaneously, the dose being 5 mg. per 
kilogram on two successive days. At the end of 
this period the animals were rendered partially 
anaesthetized by morphine sulphate in doses of 
0.25 ccm. of a 4 per cent solution per kilogram. 
The anterior abdominal wall was anaesthetized by a 
2 per cent solution of cocaine and the bladder was 
exposed and the urine expressed. The bladder 
was then returned to the abdomen and the incision 
closed. 

Two animals were employed in each experiment. 
One of the animals was given intravenously 25 ccm. 
per kilogram of a 3 per cent solution of sodium car- 
bonate, while the other animal, which served as a 
control, was given an equal volume per kilogram 
of a 0.9 per cent solution of sodium chloride. Both 
of the animals were anaesthetized by Grehant's 
anaesthetic in 60 per cent strength. The anaesthesia 
was allowed to persist for two hours and forty-five 
minutes. At the end of this time any urine which 
had been formed during the period of anaesthesia 
was expressed from the bladder and measured. 
The kidneys were removed for histological study. 



GENERAL SURGERY — SURGERY OF THE HEAD AND NECK 



129 



The animals which received the intravenous in- 
jection of the carbonate solution showed in every 
instance a much greater output of urine during the 
period of anaesthesia than did the animals which 
received the same volume per kilogram of sodium 
chloride solution. These control animals (sodium 
chloride), either became acutely anuric from the 
anaesthetic or the output of urine, as compared with 
the output by the carbonate animals, showed a 
very great reduction. 

The kidneys of the control animals showed an 
epithelium which was acutely swollen and in various 
stages of necrosis. These changes were most 
pronounced in the convoluted tubules. Accumula- 
tions of fat were marked in the loops of Henle. 

The kidneys of the animals which received the 
sodium carbonate solution showed an epithelium 
which gave but slight evidence of injury. There was 
no necrosis of the epithelium. Fat accumulations 
in the loops of Henle were slight or absent. 

In both types of kidneys the vascular pathology 
consisted in an acute engorgement of the glomerular 
vessels. There was no histological evidence of 
degeneration in the glomeruli. 

The intravenous use of a solution of sodium car- 
bonate protects the kidney acutely nephropathic 
from uranium against the toxic effect of Grehant's 
anaesthetic. 

This protection is associated with the histological 
preservation of the renal epithelium. 

George E. Beilby. 

McCarty, F. B., and Davis, B. F.: The Use of 
Warmed Ether Vapor for Anaesthesia. Ann. 
Surg., Phila., 1916, Ixiii, 305. 

As a result of experiments upon animals the 
authors found no evidences of the superiority of 
warmed over unwarmed ether vapor sufficient to 
warrant its general use. Their conclusions are as 
follows : 

I . The amount of heat required to warm ordinary 
ether vapor as used in anaesthesia by the open or 
closed methods, or by intrapharyngeal or intra- 
tracheal insufflation, to body temperature, is so 
small as to be a neglibible factor in lowering body 
temperature and in inducing shock in anaesthetized 
patients. 



2. The warming of ether vapor, however ad- 
ministered, is accomplished in the mouth, pharynx, 
trachea, and primary bronchi, and the anaesthetic 
reaches the alveoli at body temperature. 

3. The quantity of ether required to produce and 
maintain anaesthesia does not appear to be materially 
influenced by warming the ether. 

4. So-called cold vapor does not appear to be 
more irritating to mucous membranes than warmed 
ether. 

5. No more mucus and saliva is secreted when 
ansesthesia is induced and maintained with cold 
ether than when the ether is warmed. Gatewood. 

SURGICAL INSTRUMENTS AND APPARATUS 

Stewart, L. F.: Combination Needle-Holder and 
Ligature Scissors. Surg., Gynec. 6" ObsL, 19 16, 
xxii, 489. 

The instrument described is a combination needle- 
holder and ligature scissors, the holder portion of 
which is of the long shank haemostat type similar to 
the Deaver needle-holder. The needle-holder jaw 
that is superior when the holder is properly held in 
the right hand has a cutting edge that is slightly 
curved on the flat. The cutting edge is on the side 
of the jaw that would lie inferiorly when the right 
hand is rotated to the right. A scissor blade fits 
the jaw blade in contour and has a shank with a 
finger-holder that terminates just anterior to the 
finger-holder of the needle-holder shank which 
accommodates the ring-finger. The middle finger 
fits in the finger-holder of the scissor shank and 
operates the scissors. The scissor shank has a 
separate screw lock just anterior to the screw lock 
of the needle-holder. 

The scissor attachment does not affect the 
strength of the instrument, and the additional finger- 
holder makes it easier to operate. The scissors 
being curved on the flat and having a blunt extrem- 
ity permits slight possibility of injuring structures 
when cutting ligatures. 

The advantages of the instrument to one who ties 
and cuts his own ligatures is that ligatures or sutures 
can be passed, tied, and cut, without removing the 
instrument from the hand or making it necessary to 
pick up other instruments. 



SURGERY OF THE 

HEAD 

Schwartz, A., and Mocquot, P.: The Immediate 
Treatment of Head Injuries from Projectiles. 

Practitioner, Lend., 1916, xcvi, 278. 

An outline is given of the procedure in the treat- 
ment of head injuries by projectiles, as soon as they 
are brought in from the firing line. The authors 
think that every head injury should be operated 
upon at once because of the fact that cases present- 



HEAD AND NECK 

ing little external wounds may show serious damage 
to the underlying skull and brain. The procedure 
consists in the enlargement of the wounds in the 
skin and bone, the removal of splinters, and also 
of the projectile when it is present. The projectile 
should never be sought for in the brain substance 
at this early stage. Most careful haemostasis is 
essential. All wounds are provided with drainage. 
When the dura mater is intact below a fracture, 
and is of normal color and consistency, with no 



I30 



INTERNATIONAL ABSTRACT OF SURGERY 



cerebral symptoms apparent, it is not interfered 
with. If, however, the patient shows cerebral 
symptoms or if the dura is bulging or shows a blue 
discoloration beneath it, it is incised and drainage 
instituted. Penetrating wounds of the skull are 
the most serious type to deal with. It is necessary 
to trephine both at the point of entrance and exit 
of the projectile. Fragments of the skull, if they 
are loose, are taken out. Great care must be ex- 
ercised in their extraction so as not to damage the 
underlying veins during the procedure. Severe 
wounds with haemorrhage and protrusion of the 
brain substance are dealt with in a similar manner. 
A sufficient area around the wound is cleaned and 
shaved and prepared for operation as though a 
craniotomy was to be done in each instance. The 
authors prefer an H-shaped incision with the hori- 
zontal bar of the H running anteroposteriorly, 
and about twice the length of the vertical arms. 
This can readily be enlarged in any direction if 
necessary. It is advised that the drainage be left 
in place from ten to twelve days and only the super- 
ficial dressings be left up to this time when the tissues 
acquire an added immunity and enough resilience 
to keep them from being torn open by the removal 
of drainage. The authors lay stress on the import- 
ance of laying these comatose patients on good beds 
provided with rubber rings or small air cushions. 
Scrupulous attention must be paid to their bodily 
cleanliness to avoid bed-sores. Harry G. Sloan. 

Payne, J. L.: War Injuries of the Jaws and Face. 

Lancet, Lond., 1916, cxc, 569. 

Fractures of the maxilla and mandible sustained 
in war differ from civil cases of jaw injury in the 
frequency of the occurrence of multiple fractures, 
comminution of bone, loss of substance, degree of 
displacement of fragments, the frequency of foreign 
bodies, and in the cicatrization of soft tissues, most 
trouble being associated with the mandible. Jaw 
injuries could be clinically classified into six groups: 
(i) fractures of the mandible without displacement 
of the line of occlusion; (2) single fractures with 
lateral displacement; (3) single fractures with ver- 
tical displacement ; (4) two or more fractures of the 
mandible with loss of substance; (5) gunshot wounds 
of the maxilla; (6) fractures involving loss of the 
anterior portion of the mandible, the maxillae, or 
the whole of one side, together with the adjacent 
soft tissue. 

Co-operation between the general and the dental 
surgeon should eliminate unnecessary operations 
and the sacrifice of tissue which could have been 
saved. Restoration treatment may be considered 
under four heads: (i) reduction of displacement 
of bony fragments; (2) retention of these frag- 
ments in a position which allows of normal occlu- 
sion; (3) reduction of cicatricial contraction, res- 
toration of muscular equilibrium, and the remolding 
of facial tissues; (4) the fitting of a permanent pros- 
thetic apparatus. 

Union of the maxillae did not present such difficul- 



ties as that of the mandible, because of the better 
support and blood supply. In the absence of sepsis, 
union of the upper jaw usually occurs in a few 
weeks. The use of interdental splints does not 
necessarily tend to promote sepsis, as they are 
easy to keep clean. Efficient drainage is essential 
and thorough irrigation must be carried out from 
the start. To favor osseous union rest is important 
but absolute fixation is not necessary. Early at- 
tention to these cases saves loss of occlusion, such 
as has been the lot of too many patients. 

E. K. Armstrong. 

Reynolds, G. E. : Sinus Thrombosis in Compres- 
sion. /. Am. M. Ass., 1916, Ixvi, 952. 

The author formerly believed that in cases of 
acute pressure on the surface of the brain of a non- 
septic and non-malignant nature, the patient would 
recover if the pressure was removed before the vital 
centers were on the verge of complete paralysis or 
the vasomotor center near to the end of its secondary 
depression and sepsis could be excluded. Two cases 
of fatal termination after meningeal haemorrhage in 
which of the three main causes of thrombosis, viz., 
sepsis, vessel wall damage, and stasis, only the 
latter could be held accountable, has modified his 
opinion. 

In the first case operation was not done for 
sixteen hours after the original injury. A very 
extensive clot was found in the temporal region, and 
death occurred one week later without the patient 
having regained consciousness. Thrombosis of the 
longitudinal sinus and the veins leading to it was 
the only cause found. In the second case operation 
after fourteen hours of unconsciousness revealed a 
large subarachnoid haemorrhage. Necropsy the 
next day showed a firm thrombosis of the right 
lateral sinus, extending into the torcula and in- 
volving the straight sinus. In both instances the 
thrombosis was thought to be due to the prolonged 
pressure. 

These cases are further evidence in favor of early 
decompression in well established cases irrespective 
of their cause or localization. Before surgery is 
employed an accurate diagnosis is essential, as the 
most profound hemiplegias may result from nothing 
worse than an angiospasm. E. K. Armstrong. 

Skinner, E. H.: Intracranial Aerocele. /. Am. M. 

Ass., 1916, Ixvi, 954. 

The patient had sustained a fracture of the right 
supra-orbital ridge of the skull with apparent re- 
covery, but complained of dizziness and headache. 
Roentgen negatives showed a cavity containing air 
or gas and a comminuted fracture of the right frontal 
bone. The interpretation of the shadow as being 
subdural depended upon its round shape. Opera- 
tion confirmed the roentgenoscopic diagnosis, and 
analysis of the collected gas showed it to be com- 
posed of oxygen, 1.8 per cent, nitrogen, 98.2 per 
cent, being practically air from which the oxygen 
had been removed by absorption. Twenty days 



GENERAL SURGERY — SURGERY OF THE HEAD AND NECK 



131 



after operation the patient developed headache, 
temperature of 104°, and coma. Death occurred 
the next day, the necropsy showing leptomeningitis 
with a large amount of pus at the base of the brain. 

E. K. Armstrong. 

Duval, P.: Cranioplasty : Metallic, Cartilaginous, 
or by Bone-Plate (Cranioplastie par plaque 
metallique, cartilagineuse, ou osseuse). Bull, ei 
mem. Soc. de chir. de Par., 191 6, xlii, 611. 

Duval has performed 18 cranioplastie operations, 
9 of which were with aluminium plates, i bone-flap, 
and 8 cartilaginous reparations according to Mores- 
tin's method. In his early practice he used metal 
plates, but following Morestin's communications he 
used pieces of cartilage cut from the patient and he 
has now completely abandoned all other methods, 
owing to the excellent results he obtained from the 
use of cartilage. W. A. Brennan. 

Ouenu, E.: Extraction of a Projectile from the 
Brain; Use of the Bergonie Electrovibrator 

(Extraction d'un eclat d'obus du cerveau; utilisa- 
tion de I'electro-vibreur Bergonie). Bull, et mem. 
Soc. de chir. de Par., 191 6, xlii, 681. 

The patient in this case was wounded in June, 
191 5. The head wounds were multiple. Two 
pieces of projectile were discharged by the mouth 
within a short time, but radiography disclosed a 
third piece in the left zygomatic region against the 
base of the brain. Owing to persistent symptoms 
he was operated upon in January, 1916. Ex- 
ploration of the zygomatic fossa was negative, but a 
small rounded orifice was discovered at the cranial 
surface, and the Bergonie electrovibrator applied 
at this point gave very clear vibrations. The 
orifice was enlarged by trepan and the dura water 
exposed. On incising the latter the projectile was 
found embedded 2 or 3 cms. in the cerebral substance. 
It was extracted and the man has recovered com- 
pletely. W. A. Brennan. 

Throckmorton, T. B.: Cerebral Abscess, Probably 
Primarily Due to Suppurative Tonsillitis. 

Chicago M. Recorder, 1916, xxxviii, 128. 

The history is given of a man, 21 years of age, who 
complained of partial ankylosis of the jaw, ten 
months after an attack of tonsillar abscess. Fifteen 
months later he developed an abscess in the right 
temporal region which was drained, followed by a 
secondary operation to resect the necrosed zygomatic 
process, condyle, and neck of the mandible, at which 
time an area of bone was found anterior to and above 
the temporal articulatory surface entirely denuded 
of pericranial membrane. Following operation, the 
patient developed a gradually increasing right- 
sided exophthalmos and a small amount of pus was 
evacuated from the orbital cavity. He gradually 
developed symptoms of brain abscess without local- 
izing symptoms and an exploratory incision evacu- 
ated a right temporal abscess with relief of symptoms 
for a time. The patient died a month later. 



The author thinks the portal of entry for the 
organism causing the temporal abscess was through 
that portion of the skull anterior to and above the 
right temporomandibular joint, a spot made vul- 
nerable by the loss of the pericranial membrane. At 
autopsy the dura and surrounding tissues at a 
point corresponding to the denuded portion of the 
bone showed marked inflammatory changes. 

Ellen J. Patterson. 

Goetsch, E.: The Influence of Pituitary Feeding 
upon Growth and Sexual Development. Bull. 
Johns Hopkins Hosp., 1916, xxvii, 29. 

The dried powdered pituitary extract, derived 
from both the anterior and posterior lobes of the 
gland, when fed to young rats in excessive doses 
(o.i gm. daily), causes failure to gain in weight, loss 
of appetite, increased peristalsis, a mild enteritis, 
and certain nervous manifestations, such as mus- 
cular tremors and weakness of the hind limbs. 
The latter symptoms are undoubtedly due to the 
posterior-lobe element in the whole-gland extract, 
for they are similarly produced by using posterior- 
lobe, but not by using anterior-lobe extract. Even 
when whole gland is fed over a short period of time 
(from 25 to 40 days), it causes a more rapid growth 
and development and gain in weight, larger nipples 
in the female, and a coarser, drier, harsher growth 
of hair than is seen in either control animals or 
after similar administration of ovarian (corpus 
luteum) extract in equivalent dosage. In compar- 
ison with the development in control animals, the 
ovaries, tubes, and cornua of the uterus of animals 
fed with whole-gland extract are larger, more vas- 
cular, and cedematous in appearance, indicating in- 
creased development and activity. The testes show 
a considerably earlier growth and development; 
they are completely and permanently descended at 
an earlier age, and their gross weight is greater 
than in the control animal. 

The feeding of pituitary anterior-lobe extract 
causes increased weight and greater and more 
vigorous body-growth and development over the 
control. There is similarly an earlier and more ac- 
tive genital development. The fur is harsher and 
thicker. Loss of weight, enteritis, and nervous 
manifestations are not observed as in the beginning 
of whole-gland feeding. As compared with the 
control, the animal fed with anterior lobe for only 
40 days shows an earlier descent of the testes, which 
are also larger, more vascular and heavier, not only 
absolutely, but in proportion to the body-weight. 
The testis is mature at least as early as two and one- 
sixth months after 40 days of anterior-lobe feeding. 
The period of complete sexual development is 
shortened by at least one month, or about one-third 
of its normal time. Histologically, the testis at 
this age is mature; it shows an abnormally early 
and active karyokinesis, more active, in fact, than 
is seen in the testis of a normal rat at the age of 
from three to four months. The testis of the con- 
trol at this same age is quite immature. The in- 



132 



INTERNATIONAL ABSTRACT OF SURGERY 



terstitial cells do not seem to increase in number pro- 
portionately to the increase in spermatogenic cells 
and spermatozoa. The epididymis contains more 
spermatozoa and has a more active-looking structure. 
The prostatic gland, seminal vesicles, and vas 
deferens show a correspondingly early and in- 
creased development and activity. These changes 
produced by the feeding of anterior lobe indicate 
that the latter supplies the active principle in the 
whole gland responsible for the changes reported 
above, following the feeding of whole-gland extract. 

After prolonged feeding of anterior-lobe extract, 
over a period of eight or nine months, the sexual 
instincts are early awakened, along with the early 
maturity of the sex glands. As a result of this, a 
pair of rats, after anterior-lobe feeding for a number 
of months, bred earlier and oftener, the female 
of this pair having two pregnancies in seven months, 
as compared with none in the female of the control 
pair. The effect of anterior-lobe feeding lasts 
throughout the adult life of the animal. The control 
rat never reaches the degree of development and 
activity shown by the animal receiving the anterior- 
lobe extract, for even at the age of ten months, 
after eight and one-half months of anterior-lobe 
feeding, the latter still shows a greater, more active, 
and mature sexual development than the control. 

The feeding of pituitary anterior lobe to parent 
rats exerts its stimulating influence upon the off- 
spring in intra-uterine life and during lactation, and, 
when the experiment is carried further and the feed- 
ing to the young is continued after weaning, it has 
an even greater stimulating effect upon growth, 
weight, and development, and causes earlier and 
more frequent breeding and an increased number of 
offspring in the litters. The stimulating effect 
upon the sex glands is greater, the longer the in- 
fluence of anterior-lobe administration is exerted. 

The extract of pituitary posterior lobe, even after 
prolonged administration, does not stimulate 
growth in general nor the development of the sex 
glands, as does anterior lobe even after a very short 
period. Thus, for example, there is a much less 
marked development of the sex glands after ad- 
ministration of posterior lobe for seven and one- 
half months than after anterior-lobe administration 
for two and one-half months. The posterior-lobe 
element in the whole-gland extract has an undoubted 
retarding influence upon the development of the 
sex glands, an effect very similar to that of ovarian 
extract upon the testes. This is shown by the re- 
latively incomplete development of the testes, for 
example, after eight and one-half months of poste- 
rior-lobe feeding. If given in too large a dose, the 
extract causes loss of weight in the rats, a mild 
enteritis, and increased intestinal peristalsis. 

Ovarian extract (corpus luteum), when fed to the 
male, especially, causes a tendency toward the 
deposition of fat, not only in the body generally, 
but in the testes and other glands as well, with a 
resultant marked increase in weight. The fur is 
heavier and coarser than in the animal fed with the 



posterior-lobe extract. It does not cause an early 
descent of the testes. The latter are slightly heavier 
than those of the posterior-lobe-fed animal. This 
may be due, however, to an inhibiting effect exerted 
by the posterior-lobe extract rather than to any 
stimulating effect of the ovarian extract. The 
tendency to retardation of testicular development 
is, possibly, more definite after ovarian feeding than 
after posterior-lobe feeding. Corpus luteum, when 
fed to the female rat, is equally as stimulating as 
whole pituitary gland (active because of the an- 
terior-lobe element which it contains), but not so 
stimulating as the equivalent weights of anterior 
lobe. 

Following ovarian feeding there is, as compared 
with conditions in the control, increased develop- 
ment and activity of the female sex glands, increased 
follicle formation, a moderate increase in interstitial 
tissue, and increased branching of the fimbriated 
extremity of the tube. Prolonged ovarian feeding, 
e.g., for five to six months, to the male rat, as com- 
pared with the control, has the following effect: 
The gross size and weight of the testes, both abso- 
lutely and in proportion to the body development, is 
less and, histologically, the sex glands of the male 
show a retarded development and evidences of 
diminished activity. The definitely retarding in- 
fluence of ovarian extract upon the male sexual 
development is exerted throughout the animal's life. 

Briefly, then, pituitary extract (anterior lobe), 
when fed to young rats, has a stimulating effect 
upon the growth of the animal and upon its sexual 
development and activity. Posterior-lobe extract, 
when thus given, has a retarding influence. Ovarian 
extract (corpus luteum) has a stimulating influence 
upon the female and a retarding influence upon the 
male sexual development. Edward L. Cornell. 

NECK 

Plummer, W. W.: Cervical Ribs, Report of Seven 
Cases with One Operative Case, Am. J. Orth. 

Surg., 1916, xiv, 146. 

The author reports a personal experience with 
seven cases. Cervical ribs have been observed as 
unilateral or double, usually related to the seventh 
cervical vertebra, and varying in completeness from 
a fully developed rib with articulations and muscle 
attachments down to a mere enlargement or over- 
growth of the costal process of the vertebral unit. 
The commonest chnical evidence of the presence 
of the extra rib has been a neural disturbance in the 
arm associated with pain, or pain and varying de- 
grees of paralysis referable to the distribution of 
the ulnar nerve, and suggesting pressure on or in- 
jury to the eighth cervical root. Less frequently 
disturbances in the circulation of the upper ex- 
tremity, and spinal deviations have been observed. 
Apparently the size and shape of the rib do not bear 
any definite relation to the intensity of the symptoms 
produced. Many cases are discovered accidentally. 

Philip Lewin. 



GENERAL SURGERY — SURGERY OF THE HEAD AND NECK 



133 



Holding, A. F.: The Non-surgical Treatment 
of Tuberculous Glands. Med. Rec, 1916, 
Ixxxix, 471. 

Having observed the good effects of roentgen rays 
on tuberculous glands during the past fifteen years, 
Holding expresses surprise that the method is little 
known and seldom advised by the medical profes- 
sion. He illustrates this by quotations from several 
recent writers. 

Holding states that in caseous glands, or those 
that have begun to break down in the center, pus 
formation is hastened by the roentgenization so that 
the lesion rapidly increases in size. Unless fore- 
warned the patient usually becomes frightened at 
this condition, thinking that the glands are being 
made worse by the treatment. They soon " point," 
and after an incision and evacuation of the pus 
these cases usually progress uninterruptedly to 
cures. 

The best results from roentgen therapy are ob- 
tained in the advanced caseous lesions or those in 
which sinuses have formed; that is, in cases in which 
external drainage obtains. 

In the early hyperplastic form of the disease, 
slower and less brilliant results follow X-ray treat- 
ment. Patients in whom the periphery of the 
lesion is ill-defined, cedematous, and actively ad- 
vancing are much less favorable operative risks 
than when the glands have no periadenitis, are 
discrete, and not active. In these cases a tentative 
course of X-ray treatment is advisable even if 
subsequent operation is contemplated. This will 
reduce the activity of the process, stop peripheral 
extension, and reduce the lesion in size, and it can 
be removed surgically if time is a factor. If surgical 
removal is to be done after the active process has 
been controlled by roentgen therapy the operation 
should be performed before sufficient time has 
elapsed to allow post-roentgen fibrosis to develop. 

Seventy cases of tuberculous glands treated by 
Holding were classified, according to Blaisch, as 
follows: (i) hyperplastic type, 16; (2) caseous or 
purulent type, 24; (3) ulcerated or fistulous type, 30. 

In the first class 3 became symptomatically well; 
2 were improved and relapsed later and were symp- 
tomatically cured by a second course of treatment; 
5 disappeared from observation; 5 were improved 
and later submitted to an operation; i was un- 
improved. 

In the second class 19 became symptomatically 
well; 2 disappeared from observation; 3 were im- 
proved. 

In the third class 25 became symptomatically 
well; 5 disappeared from observation. 

The essentials of deep roentgen therapy are the 
use of the Coolidge tube, high voltage, measured 
maximum skin dosage, crossfiring, and filtration of 
the rays, given in three to ten series of treatments. 
If the dose to each skin area is limited to 1 5X (Kien- 
boeck), no disagreeable skin symptoms will follow. 

The conclusions are: 

I. The efficacy of X-ray treatment in tuberculous 



adenitis has been demonstrated, over 1,500 success- 
ful cases having been reported. 

2. The surgical treatment which was orthodox 
before the discovery of the X-rays and their thera- 
peutic value is still advised by many members of 
the medical profession. 

3. Non-surgical methods, including the X-rays, 
deep hyperaemia, and tuberculin, should be tried 
before any case is submitted to radical operation. 

DAvm R. BowEN. 

Reder, G. J.: Cerebral Nerve Disturbances in 
Exophthalmic Goiter. Am. J. M. Sc, 1916, 
cli, 339- 

The author calls attention to the cerebral nerve 
palsies which occur in exophthalmic goiter as rare 
manifestations of the disease. Not more than 80 
cases in all are recorded, there being only 4 cases 
reported in American literature. The case reported 
is the first instance which has come under observa- 
tion in the Johns Hopkins Hospital. 

The patient was a Russian Jew, aged 23 years. 
A year after the appearance of the goiter (1910) 
the patient became aware of a droop of the right 
upper lid; a similar condition of the left lid soon 
followed. This bilateral ptosis gradually became 
more marked. Soon after the appearance of the 
ptosis the patient was troubled with double vision, 
which persisted. About five weeks before admis- 
sion, owing to loss in the power of mastication he 
was unable to chew solid food. For a month he 
had had difficulty in speech, jumbled his words and 
talked through his nose. A week before admission 
he lost his voice completely for a period of three 
days. For the same period his tongue felt thick. 
He had difficulty in swallowing, and fluids taken by 
mouth were repeatedly regurgitated through the 
nose. Great weakness of the upper and lower limbs 
compelled the patient to give up work. 

A striking feature on examination was the pa- 
tient's facial appearance: drooping lids, pro- 
truding fixed eyes, mask-like face, open mouth, and 
hanging jaw. He was extremely weak and suffered 
from marked dyspnoea. Unable to expel mucus 
which collected in his throat he had frequent violent 
paroxysms of coughing. His voice had a nasal 
quality. He was clear mentally, but emotional. 
Exophthalmos was extreme. The thyroid was 
much enlarged. There was complete bilateral 
ptosis and fixatioji of the globes. The pulse was 
about 120 per minute and there was well-marked 
tremor of the fingers. The hands and feet were 
perspiring. Pigmentation was pronounced. Nau- 
sea, vomiting, and a rather persistent diarrhoea 
were complained of during his illness. The blood 
count showed white cells 9,000; polymorphonuclears, 
71 per cent. 

Double vision was constant. Movements of the 
head from side to side had no influence on the posi- 
tion of the eyeballs. There was complete ophthal- 
moplegia externa, a complete paralysis of the third, 
fourth, and fifth cerebral nerves. The fifth motor 



134 



INTERNATIONAL ABSTRACT OF SURGERY 



seemed markedly involved. Facial weakness was 
manifest on both sides. 

Ligation of the superior thyroid arteries was per- 
formed. Death occurred on the second day, due 
apparently to acute respiratory paralysis. 

The literature on cerebral nerve disturbances in 
exophthalmic goiter is summarized by Heuer, who 
calls attention to a comprehensive article by 
Sattler and Kappis published in 191 1. Reported 
cases show that the oculomotor nerve has been most 
frequently affected. Single muscles or all the 
muscles supplied by this nerve have been involved. 
Kappis collected over 40 cases in which the eye 
muscles alone were affected. Isolated palsies may 
occur, but combinations of various kinds are most 
commonly seen. A pure ophthalmoplegia externa 
has been observed in 6 cases. Isolated palsy of 
the fifth motor has not been observed; combined, 
this nerve has been affected five times, chiefly in 
cases of bulbar paralysis. 

With the exception of palsy of the facial, 5 cases 
of which have been reported, isolated palsies of the 
remaining cerebral nerves are extremely rare. 
Combined palsies of these nerves are not uncom- 
mon, and the most varied clinical pictures occur. 
The spinal accessory appears to be the only cranial 
nerve which has escaped involvement in exophthal- 
mic goiter. 

The cases with bulbar paralysis have all been 
severe cases of exophthalmic goiter, and in most 
instances the disease has run a rapid course. Death 
has invariably followed the appearance of these 
symptoms, and in the majority of instances within a 
short time. 

As regards the etiology of nerve palsies in exoph- 
thalmic goiter, it is assumed that the disturb- 
ances are of a toxic nature. 

Comparatively few pathological lesions in the 
brain have been recorded in the cases of exophthal- 
mic goiter with nerve palsies, though in 4 of the 6 
cases with bulbar paralysis in which autopsies were 
obtained, definite lesions were present in the 
medulla associated with extensive degeneration of 
fiber tracts. 

The palsies may appear at any stage of the dis- 
ease. In most cases they manifest themselves 
months or even years after the onset of the disease. 
They may begin insidiously or quite suddenly. In 
no case has the palsy been benefited by operation, 
although marked improvement in other symptoms 
has been noted. There are 2 cases, however, in 
which palsies of short duration have disappeared 
without operation on improvement of the other 
symptoms, and 3 cases in which there was a partial 
recovery of the palsies. 

In the differential diagnosis, myasthenia gravis, 
which is at times associated with exophthalmic 
goiter may cause uncertainty as to diagnosis. 
Sattler reports 6 cases in which a positive myasthenic 
reaction was obtained, with variation from day to 
day in the palsies. Brain tumor, cerebral haemor- 
rhage, multiple neuritis, and multiple sclerosis 



have all been observed associated with exophthalmic 
goiter and might also give rise to some difficulty in 
diagnosis. E. H. Pool. 

Swan, J. M.: Observations on the Blood-Pressure 
in Gases of Dystliyroidism. Interst. M. J., 1916, 
xxiii, 186. 

Swan gives an account of blood-pressure observa- 
tions made in 50 cases of dysthyroidism in varying 
degrees of intensity. The cases were analyzed with 
regard to systolic, diastolic, and pulse pressures, 
as well as to the functional capacity of the heart. 
Riva-Rocci and Tycos instruments were used with 
a twelve-inch cuff. The author adopted Woley's 
figures as normal for the different ages. Systolic 
pressure for persons between 15 and 30 years of 
age was 122, between 30 and 40, 127, and from 40 
to 50, 132 mm. 

The author divided his series into three classes. 
Of the 50 cases, 21 had a normal blood-pressure 
for their age; 15 had a low pressure; and 14 had a 
high blood-pressure. Detailed charts were given, 
covering the various observations and their time 
intervals. Several blood-pressure charts, taken 
during operation for thyroidectomy, were also 
given. 

The following conclusions were drawn: (i) The 
effect of thyroidism on the blood-pressure is to 
lower the systolic; this is accompanied by an 
increase in the pulse pressure. (2) After the case 
has persisted for a varying period, and after the 
development of cardiac hypertrophy and vascular 
changes, the cases are converted into typical 
examples of chronic hypertension. (3) The myocar- 
dium is disturbed in nearly all cases, whether there 
is clinical evidence of such disturbance or not. 

Harry G. Sloan. 

Kendall, E. C: The Function of the Thyroid- 
parathyroid Apparatus. /. Am. M. Ass., 19 16, 
Ixvi, 811. 

No complete hypothesis can be formulated at 
this time when many other factors remain so 
obscure, but the process occurring in the normal 
animal may be outlined as follows: The body 
proteins are decomposed to a slight extent into 
amino acids. These, under proper conditions and 
in the presence of the iodine compound, are de- 
aminized and the products of this reaction are then 
burned either directly into carbon dioxide and water 
or are used for the formation of carbohydrates, 
fats, etc. If, for any cause, an increase in the 
amount of the iodine compound in the cell is brought 
about, the speed at which this reaction takes place 
is increased, the equilibrium between proteins and 
amino acids is disturbed, more amino acids pass 
into the reaction, and ultimately the proteins, 
unless replenished, are exhausted. At the same 
time the products of the reaction, deaminized 
acids, are formed in increased amount. This results 
in an increased speed of the processes of oxidation 
and the formation of carbohydrates and fats. The 



GENERAL SURGERY — SURGERY OF THE CHEST 



135 



delicately balanced relations between proteins, 
carbohydrates, fats, and oxidation are, therefore, 
affected at a vital point since the equilibrium of 
the entire body is changed and the speed of reaction 
of all body functions is increased. 

The presence of the deaminizing catalyzer does 
not affect the mechanism of the formation of 
body proteins from foreign proteins, or the decom- 



position of body proteins into amino acids. There 
is no direct change in the mechanism entering into 
the metabolism of carbohydrate and fat formation 
and oxidation. The only thing which is influenced 
is the rate at which deamination occurs. If this 
hypothesis be correct, evidently the function of the 
thyroid is to furnish a catalyzer which regulates the 
rate of deamination. Edward L. Cornell. 



SURGERY OF THE CHEST 



CHEST WALL AND BREAST 

Sekiguchi, S. : Hypophyseal Disorder in Mammary 
Cancer and Its Relation to Diabetes Insipidus. 

.4mm. Surg., Phila., 1916, Ixiii, 297. 

Diabetes insipidus has been divided into the 
symptomatic, due to some organic brain disease, as 
irritation of the medulla, pons, or cerebellum, and 
the idiopathic which occurs without any patho- 
logical findings and without any accompanying 
clinical symptoms. The latter is not to be confused 
with hysteropsychopathic polyuria or that pro- 
voked by some emotional stress, but is probably a 
disordered kidney function. 

Certain diseases of the hypophysis, such as 
acromegaly and adiposogenital dystrophia are 
often accompanied by diabetes incipidus. Sim- 
monds has published the opinion that diabetes 
insipidus occurring in patients with carcinoma of 
the breast was caused by metastasis into the hy- 
pophysis. On account of Simmonds' work, the 
author investigated 35 hypophyses in cases of 
mammary cancer coming to autopsy. In two of 
these cases polyuria appeared in the late stage of 
the disease with no evidence of renal disorders. 
In each instance cancer metastasis in the posterior 
lobe of the hypophysis was found, with no patho- 
logical changes in the gray matter of the third 
ventricle. These cases are well explained according 
to the theory of Schaefer, as it seems quite likely 
that the tumor in the pars posterior compressed 
the pars intermedia sufficiently to develop a 
hypersecretory function. This increased secretion 
in turn stimulated the epithelium of the kidneys to 
the overproduction of urine. Gatewood. 

Hoxie, G. H. : Thymic Disturbances in the Adult. 

A^. Y. M. J., 1916, ciii, 676. 

The author reports a case of enlarged thymus, 
in which the chief complaint was weakness and 
difficulty in breathing. Fluoroscopic examination 
showed a dark area beneath the upper part of the 
sternum. The symptoms gradually improved un- 
der thyroid and arsenic administration. The 
condition, however, was not relieved, for periodically 
the patient returned until finally an operation was 
performed. 

The first and second costal cartilages were re- 
sected, together with a portion of the manubrium. 



A glandular mass was found three-fourths of an 
inch long and three-eighths of an inch in diameter. 
It was removed and had the appearance of a per- 
sistent thymus. The patient recovered completely. 
Several other cases are reported by the author 
in which improvement followed the administration 
of products of glands of internal secretion. Many of 
these cases had been diagnosed as neurasthenia or 
hysteria. J. H. Skiles. 

TRACHEA AND LUNGS 

Dunham, K.: Roentgenographic Diagnosis of 
Pulmonary Tuberculosis. Am. J. Roentgenol., 
1916, iii, 131. 

Dunham reports his findings from serial micro- 
scopic section of blocks from lungs previously ex- 
amined by the stereoscopic roentgen method, calls 
attention to findings previously reported, and 
reaches the following conclusions: 

1. In the X-ray we have an excellent means of 
studying the fundamental principles of pathology. 
It accurately indicates abnormal density, and when 
we learn where these densities are located and to 
what they are due we may solve many pathological 
problems. When our ideas of pathological con- 
ditions will not explain the X-ray findings we have 
presented a valuable field for research. 

2. The X-ray will often provide the first definite 
knowledge of the existence of tuberculosis, but a 
diagnosis of tuberculosis is not of great value unless 
it can be accompanied with a fairly accurate prog- 
nosis, and nothing has ever been of such prognostic 
value as the roentgen findings, unless it be the 
physical condition of the patient. 

Three conditions argue for a bad prognosis: 
cavity, involvement of the bases if at all extensive, 
and laryngeal tuberculosis. Two of these are best 
determined by means of the roentgen ray. 

Davk) R. Bowen. 

Rist and Holland : Pulmonary Gangrene of Otitic 
Origin (Gangrene pulmonaire d'origine otitque). 
Presse mid., 1916, p. 149. 

The patient whose case is reported by the authors 
arrived at the hospital in a grave condition with 
fever, thoracic pains, dyspnoea, etc. Central 
pneumonia was suspected. At the same time 
there was found a running from the ear which the 



136 



INTERNATIONAL ABSTRACT OF SURGERY 



patient said had lasted several weeks. After three 
or four days there was a zone of inflammation at the 
base of the left lung and the expectoration became 
foetid. The general state became aggravated and 
the patient died. 

At autopsy a large number of disseminated, 
embolic, gangrenous foci were found in both lungs, 
in different stages of evolution. The origin of this 
pulmonary gangrene was sought in the ear; an old 
middle-ear ostitis was found, also a mastoiditis with 
obliteration of the cells, and an obliterating phlebitis 
of the lateral sinus and of the internal jugular. The 
meninges were not attacked. 

These pulmonary complications of chronic otitis, 
frequent in children, are very rarely met with in 
adults. Like all other suppurative complications 
of chronic otitis they have a foetid, putrid, and 
gangrenous character, and their gravity is such as to 
call for early treatment by a specialist. 

W. A. Brennan. 

Villeon, P. de la: Operative Extraction of Intra- 
pulmonary Projectiles both Deep and Super- 
ficial, Under the (Radioscopic) Screen, by a 
Simple, Rapid, and Sure Process (L'extraction 
operatoire des projectiles intrapulmonaires, super- 
firiels et profonds, sous I'ecran par unprocede 
simple, rapide, et siir). Bull. Acad, de tned., Par., 
1916, Ixxv, 275. 

In the great majority of cases the operation of 
thoracopneumotomy for the extraction of intra- 
pulmonary projectiles may be replaced by a simpler 
procedure which the author has devised and de- 
scribes in detail. After locating the foreign body the 
patient is placed under the screen, a buttonhole 
incision is made over the location through which a 
closed extracting forceps is introduced; and, under 
the guidance of the radioscopic projection, pushed 
through an oblique trajectory until it reaches the 
body. The forceps is then opened, the body seized 
and extracted. There is neither pneumothorax nor 
haemothorax. The author has extracted 17 intra- 
pulmonary projectiles by this procedure, of which 8 
were deep. He has also extracted 20 intrapleural 
projectiles and several of his colleagues have success- 
fully employed the method. Thoracopneumotomy 
is now only exceptionally done. W. A. Brennan. 

Georg, C, Jr. : Some Experiments in Lung Surgery. 

/. Mich. St. M. Soc, 1916, xv, 135. 

Georg reports 18 resections of the lung performed 
experimentally on dogs. These operations were per- 
formed with Meltzer's insufflation apparatus with 
the idea of determining the dangers which may ac- 
company this method of anaesthesia. The article is 
illustrated with three photographs of dogs which re- 
covered from the operation and two photographs of 
their lungs which were removed after killing the 
animals with ether two to six months after opera- 
tion. Pathologic sections of the lungs were made 
in all cases by Dr. A. S. Warthin. 

The author gives a historical review of the most 
important experimental work which has been done 



upon the use of both positive and negative pressure 
in the surgery of the lungs. In general the results 
have been much better following the use of negative 
pressure than positive, because the former produces 
conditions more closely resembling the physiological. 
Thus Cloetta (1910-1913) showed, by means of a 
special lung plethysmograph in which he placed 
the lungs and stopped the respiratory movements 
by means of curare, that if the lung is distended to 
exactly the same degree by positive and negative 
pressure one third less pressure is required with the 
negative than with the positive, or if the same 
amount of pressure is used in each case the lung 
will be more distended with negative pressure. 
Georg's experiments show that a slight degree of 
positive pressure is not dangerous, but if the pressure 
is too high or too low it may result in serious re- 
flex disturbances in the lungs and deleterious effects 
upon the circulation, depending upon the reserve 
power of the right ventricle. 

All animal experiments seem to show that total 
extirpation of one lung has a higher mortality with 
positive pressure than with negative, because the pres- 
sure of air in the empty pleural cavity which cannot 
be entirely driven out prevents the collapse of the 
chest wall and changes in the position of the dia- 
phragm, mediastinum, and sound lung which is 
necessary for recovery. 

Resection of the lung is a very dangerous opera- 
tion both on dogs and on the human on account of 
the risk of pneumothorax and the difficulty of mak- 
ing a hermetic closure of the bronchus and lung. 
Infection may occur from the external wound or 
from the presence of germs in the nose and throat 
which are driven into the bronchi and lungs by the 
insufflation apparatus. The author's experiments 
show that this is true of operations upon dogs which 
are often affected with distemper. 

When lung resections are done under positive 
pressure an exudate usually forms in the pleural 
cavity. This the author found to be true but Kawa- 
mura found no exudate after his operations. 

Dogs are especially unfavorable subjects for lung 
operations on account of the shock which results 
from exposure and loss of body temperature, their 
inability to stand pneumothorax well, and their 
low resistance to infection in the pleural cavity. 

The exudate which forms after a thoracotomy 
causes compression of the lung, which has a bad effect 
upon the circulation and function. Georg proved 
that secondary infection of the compressed lung 
may result in the formation of areas of pneumonia. 
In the case of wounds of the lung in man, pneumo- 
thorax may be prevented by the use of Tiegel's 
drain. The anatomy of the dog accounts for its 
low resistance to pneumothorax. The thorax in 
man offers considerable resistance to pneumothorax 
as in only about 5 per cent of intrathoracic operations 
does it become necessary to use any apparatus to 
prevent pneumothorax. 

In the dog these conditions are different as the 
animal will die in a few minutes if a wide opening is 



GENERAL SURGERY — SURGERY OF THE ABDOMEN 



137 



made in the chest without the use of differential 
pressure. This is due to the fact that its mediasti- 
num is so loose and delicate that it flutters up into 
the wound and often becomes perforated, thus al- 
lowing air to get into the sound half of the thorax 
resulting in double pneumothorax. 

A series of pneumectomies were performed upon 
dogs at the surgical laboratory of the University 
of Michigan, Meltzer's apparatus for intratracheal 
insufflation being used. These operations were all 
done under aseptic conditions. The author draws 
the following conclusions from the results of these 
experiments:. Intratracheal insufflation was not 
without harmful effects upon the lungs even in 
those dogs that recovered. Interstitial emphysema 
and overdistention of some of the alveoli of the 
lung were shown microscopically. These changes 



were much more marked in the animals that died 
than in those that recovered and consisted of large 
haemorrhagic areas with tearing of the walls of the 
alveoli. Insufflation also has a very harmful effect 
upon the circulation in the lungs as is shown by the 
intense congestion and atelectasis found micro- 
scopically. 

The transplantation of a strip of fascia lata upon 
a wound in the lung gives an added protection to it 
from infection. Preliminary ligation of the bronchi 
and careful suture of the lung tissue must always be 
done. After the suturing is complete, careful search 
must be made for the escape of air from the lung 
wound by moistening it with salt solution. For 
intratracheal insufflation a No. 18 to 24 French 
catheter should be used and the pressure should be 
maintained at 20 to 25 millimeters of mercury. 



SURGERY OF THE ABDOMEN 



ABDOMINAL WALL AND PERITONEUM 

Rouvillois, H., and others: Clinical and Therapeu- 
tical Study of Abdominal Wounds in War 
Surgery (Etude clinique et therapeutique sur 
las plaies de rabdomen en guerre). Bull, et mem. 
Soc. de chir. de Par., 1916, xlii, 708. 

Owing to the importance of the subject and the 
many and diverse opinions expressed by surgeons 
on the treatment of abdominal injuries the authors 
have made a thorough and detailed study of the 
entire question and their exhaustive report occupies 
the greater part of the present issue of the bulletin 
of the Society of Surgery. In the early part of the 
war the authors like others labored under the dis- 
advantage that the conditions at the front offered 
to the systematic practice of abdominal surgery; 
but later the ambulance service was provided with 
all the necessary equipment for successful inter- 
vention. The authors were situated about 18 kilos 
from the first line of trenches and hence the wounded 
did not generally reach them for an interval of 
from six to seven hours after injury. 

Altogether they observed 247 abdominal wounds, 
which they divide into: (i) extraperitoneal wounds 
— parietal or visceral; (2) peritoneal wounds — 
simple or visceral; and (3) thoraco-abdominal 
wounds. In all 133 cases are reported in detail 
under these headings. 

Extraperitoneal injuries, parietal or visceral, do 
not as a rule present very difficult problems, but 
with peritoneal wounds where the serous or an intra- 
abdominal organ is involved the outcome is more 
doubtful. In 74 laparotomies for peritoneal in- 
juries a very abundant haematocele was observed in 
38, and in only 2 of these were lesions of the large 
intra-abdominal vessels demonstrated. Of the 
40 cases which were laparotomized immediately 
for univisceral wounds, 23 were of the small in- 
testine, 8 of the large intestine, 9 of the liver, spleen, 



etc. Of the 21 cases of multivisceral wounds which 
were laparotomized, 10 were in the small intestine 
and colon. 

During the winter of 1914, owing to the lack of 
facilities, it was found necessary to perform 28 
Murphy operations. The results from these led 
to the conclusion that the method had no thera- 
peutic value. Of the 28, 5 recovered, but the au- 
thors are of the opinion that these cases would have 
recovered without intervention. They believe 
that laparotomy with immediate repair of the le- 
sions is the only logical and acceptable procedure, 
and they have confined themselves to this practice 
for the past eight months. 

The results of their observations are as follows: 

Abstention. The mortality of 67 non-operated 
peritoneal wounds was 89.5 per cent. Strictly 
speaking these cases could be reduced to 61 in which 
deliberate medical treatment was adopted and the 
mortality in these cases was 100 per cent. 

Murphy operation, 28 cases, mortality 82.1 per 
cent. 

Laparotomy, 74 cases, global mortality of 73 
per cent. 

Of the laparotomies, 5 were exploratory. Of the 
other 69, 64 were for peritoneal wounds and 5 for 
thoraco-abdominal wounds. Analysis of the figures 
shows: for simple peritoneal wounds, mortality, 
nil; for visceral peritoneal wounds, mortality, 80.3 
per cent. 

Again subdividing the results into univisceral and 
multivisceral injuries, the mortality for the former 
is 75 per cent and for the latter 90.5 per cent. 

Regarding the nature of the projectiles causing the 
injuries the authors were able to identify them in 86 
cases: 2;^ injuries were from bullets, with a mortality 
of 52 per cent, and 63 were shell or grenade injuries, 
with a mortality of 73 per cent. The mortality 
from the standpoint of the time elapsing between 



138 



INTERNATIONAL ABSTRACT OF SURGERY 



the period of injury and that of operation was as 
follows: operated upon during the first six hours, 
84.8 per cent; operated upon between seventh and 
twelfth hours, 80 per cent; operated upon between 
thirteenth and twenty-fourth hours, 83 per cent; 
operated upon after twenty-four hours, 66.6 per 
cent. 

The authors' conclusions are that abdominal 
wounds in war, as in peace, are amenable to im- 
mediate surgical treatment. The contra-operatory 
indications are not confined to war conditions; they 
are those indicated by general surgical practice. 

The authors rather disapprove of treatment of 
abdominal injuries in shelters close to the firing line 
because they are too much exposed to shell fire and 
explosions. They think that surgical ambulances 
situated about 12 kilos from the firing line best 
answer all purposes, these being in constant auto- 
mobile connection with the front. The inconven- 
iences of transport are fully compensated for by the 
added surgical comfort and the greater facilities 
for the necessary post-operative care. 

W. A. Brennan. 

Huertas, J.: Some Observations on Abdominal 
Wounds and Their Treatment (Algunas con- 
sideraciones sobre las heridas del abdomen y su 
tratamiento). Rep. med. y dr., Bogota, 1016, vii, 
256. 
The author considers that in cases of severe 
abdominal penetrating wounds with extreme collapse 
where other means of intervention are not applicable 
or contra-indicated, the Murphy drainage method is 
the only one suitable. Surgical intervention was 
resorted to in 15 cases of perforating wounds. 
The abdomen was incised and suprapubic drainage 
with an inclined posture of the patient instituted, 
according to Murphy's method, and three cures 
were obtained, the mortality rate being 80 per cent. 
On account of this high mortality, the author de- 
cided to perform laparatomies, observing system- 
atically all visceral lesions in each and every patient, 
the results being a cure in five cases, a mortality 
rate of 55 per cent. 

Total abstinence from surgical interference is 
practicable in cases of wounds of 2 or 3 days' duration, 
and the patient's condition is satisfactory; or in 
cases of precocious collapse where no other inter- 
vention is desirable or indicated except the reanima- 
tion of the patient. 

A median laparatomy is considered the most 
practical and ether anaesthesia the safest. 

Raoul L. Vioran. 

Picque, R. : Evolution of the Treatment of Abdom- 
inal Wounds in an Ambulance at the Front 

(Evolution du traitement des blessures de I'abdomen 

dans una ambulance de I'avant). Bull, et mem. 

Soc. de chir. de Par., 1916, xlii, 545. 

Picque points out the almost marvelous results 

from early surgical intervention in the field in the 

case of even severe abdominal penetrating visceral 

injuries. 



Analyzing the available figures he finds that ab- 
stention gave a recovery of 6 per cent; 14 palliative 
operations gave no recovery; laparotomy in general 
gave about 40 per cent of recoveries. 

Picque states that the global statistics of the war 
show the rarity of spontaneous recovery, the use- 
lessness of palliative operations, and the absolute 
innocuity of laparotomy. 

The results show that abdominal wounds are no 
longer beyond the resources of surgery when the 
injured are treated early in the surgical ambulances 
near the firing line. 

With the means now available all operable abdom- 
inal wounds should receive prompt operative treat- 
ment. By operable wounds he means all those 
arriving at the ambulance before the sixth hour 
after injury, sometimes even within ten hours; those 
who have not multiple serious wounds; those who 
are not in a state of shock or extreme anaemia, or 
with generalized peritonitis ; finally, those who have 
no large abdominal evisceration. W. A. Brennan. 

Chevassu, M.: Study of 210 Abdominal Wounds 
Observed During 15 Days in an Automobile 
Surgical Ambulance; the Favorable Results of 
Abstention (Etude sur 210 cas de plaies de Tabdo- 
men observees en 15 jours dans une ambulance 
chirurgicale automobile; et en particulier sur les 
resultats heureux des methodes abstentiounistes). 
Bull, et man. Soc. de chir. de Far., 1916, xlii, 646. 

Chevassu presents a long and important report 
on the treatment of penetrating abdominal wounds 
in war. 

In the early part of the war it was seen that three 
factors were essential for successful treatment of 
abdominal wounds at the front: rapid evacuation, 
materials, and experienced surgeons. When there 
was no efficient surgical installation abstention 
gave better results than intervention. 

Now there are fixed installations placed quite at 
the front, fully equipped and well protected; more- 
over there is an automobile service equipped with 
experienced surgeons, and early intervention is 
assured in either the advanced post or the automo- 
bile. The operatory results are much better and 
therefore intervention is a matter of choice. Still 
the general mortality is very high, and Chevassu 
thinks that if intervention cannot be made under 
conditions which promise success, abstention is 
advisable. 

In the discussion of results only intraperitoneal 
wounds are regarded as abdominal wounds. 

Of 210 abdominal wounds observed, 136 were 
peritoneal, of which 57 died and 79 were evacuated, 
a mortality of 41.91 per cent. Of the 57 deaths, 27 
or 47.36 per cent, had been operated upon; 27 were 
not operated upon; 3 were late operations. 

These results are very dift"erent from the 92 per 
cent mortality in the cases reported by Caudrelier 
and Stern which could not be operated upon. 

Of the 57 deaths, 20 occurred in the first 24 hours, 
and of these 8 had been operated upon, some dying 



GENERAL SURGERY — SURGERY OF THE ABDOMEN 



139 



during the operation or immediately afterward of 
shock. 

Of the 79 treated by evacuation, 66 did not under- 
go any intervention, 13 were operated upon. 

Of the 136 injuries that were stated to be perito- 
neal, there is no question of this as regards 100 which 
were clinically established. Of these 100 cases 
of established penetrations, 53 died — 53 per cent — 
15 deaths being immediate, neither intervention nor 
abstention being responsible. The 85 valid cases 
therefore show a mortahty of 44.7 per cent; and in 
the 36 cases where the lesion of a viscera is only 
probable the mortality is 11. 11 per cent. 

The consideration of these results has converted 
Chevassu from being, as he was at first, an ab- 
stentionist by necessity into being an abstentionist 
by choice. 

Tuffier who presented this report on behalf of the 
author is not convinced that abstention is the better 
policy. In position warfare where the surgeon is 
well equipped and ably seconded he would not op- 
pose laparotomy which, when the patient's condition 
and the organization permits it, offers a much better 
prognosis. 

While as a rule wounds of the liver and stomach 
are less formidable than other penetrations and 
may in certain cases benefit by a policy of abstention, 
unfortunately there is no sign by which the exact 
conditions can be judged, and laparotomy alone 
under suitable conditions allows the making of a 
precise diagnosis and prevention of peritoneal 
infective complications. W. A. Brexnan. 

GASTRO-INTESTINAL TRACT 

Andresen, A. F. R.: Infections of the Mouth, Nose, 
and Throat, as Primary Foci for Infections in 
the Gastro-Intestinal Tract. Long Island M. 
J., 1916, X, 102. 

It has been extremely interesting to note the al- 
most invariable presence of infective foci in cases 
of gastro-intestinal infections. These foci, with a 
few exceptions in cases where they were located in 
the skin (boils or erysipelas), rectum (ischiorectal 
abscess), or pelvis (post-partum or post-abortal 
infections), were usually found in the mouth, nose, 
or throat. The following table shows the relative 
frequency of these different focal infections in a 
series of gastro-intestinal cases observed in the 
Brooklyn Hospital Dispensary. Infections of tur- 
binates, sinuses, posterior nasal fossa, tonsils, etc., 
have been grouped under the heading of nose and 
throat infections, and all cases of infections of teeth 
and gums, past or present, under the heading of 
pyorrhoea. Nearly all cases of infections of the 
nose and throat had a pyorrhoea also present, but 
not all cases of pyorrhoea showed infections of the 
nose and throat. This raises the question whether 
pyorrhoea may not be an etiological factor in many 
of these infections of the nose and throat, and ex- 
plains why treatment of the latter conditions is un- 
successful if the teeth are not attended to. 



Total Nose and Pelvic Skin 

Cases Pyorrhoea Throat Infec- Infec- 

Disease Infections tions tions 

Gastric Ulcer 64 57 6 .. i 

Appendicitis 41 26 3 11 i 

Gall-bladder disease 18 17 i 

Diabetes 5 5 

Gastric carcinoma 8 8 

Total 136 113 9 12 2 

Per cent 83 6 to i 

The conclusions to be derived from a study of the 
facts presented are as follows: 

1. The importance of infections of the mouth, 
nose, and throat in the etiology of infections of the 
gastro-intestinal tract has been definitely established. 

2. The treatment of infective lesions of the 
gastro-intestinal tract must be modified to take 
cognizance of this newer knowledge and should 
include the following: 

(a) The use of autogenous vaccines made from 
infective material obtained from any accessible 
foci of infection. 

(b) Removal of infective foci as early as possible, 
preferably before the institution of any other line of 
treatment. 

(c) Adequate medical treatment, including diet, 
hygiene, and the correction of errors in posture and 
other deformities. 

(d) Suitable operation wherever indicated. 

3. As a prophylactic measure, prompt attention 
should be paid to all mouth, nose, and throat in- 
fections as soon as they are discovered. 

Edward L. Cornell. 

Soresi, A. L.: Perforations of the Various Abdom- 
inal Organs; a Clinico- experimental Study to 
Determine When and Where There Should Be 
Surgical Intervention (Perforazione dei varii 
organi addominali; studio clinico-sperimentale per 
stabilire se e quando si debba intervenire chir- 
urgicamente). Gior. d. r. Accad. di mcd. di Torino, 
1915, Ixxviii, 390. 

Soresi of New York, who is now serving on the 
surgical staff of the Italian army at Turin, states 
that it is the general opinion of surgeons that 
where there is a manifest perforation of the stomach 
or intestine operation must always be made. To 
determine whether in such a perforation, due either 
to traumatism or disease, there are conditions which 
might render surgical interference dangerous, a 
large number of experiments in dogs were made. 
These were divided into four classes: 

1. Animals which after perforation of the 
stomach or intestine had been made were left to 
themselves. 

2. Animals which were operated upon three hours 
after perforation of the stomach or intestine. 

3. Animals operated upon 24 hours after per- 
foration. 

4. Animals operated upon 48 hours after perfora- 
tion. 

Altogether 240 dogs were experimented on: 80 
for stomach perforations, and the others for various 
portions of the intestinal tract. 



I40 



INTERNATIONAL ABSTRACT OF SURGERY 



The experimental results demonstrated these 
facts: 

1. All perforations in the region of the ileum 
and the caecal cul-de-sac recover spontaneously 
when not operated upon. 

2. Wounds of the stomach may recover spon- 
taneously. 

3. Duodenal and colonic perforations are always 
fatal when left to themselves; i.e., when not op- 
erated upon. 

4. All wounds of the stomach, duodenum, ileum, 
caecal cul-de-sac, and colon are cured if operated 
upon 3 hours after injury. 

5. The mortality increases in all cases as the time 
between the injury and intervention increases. 

6. In perforations in the region of the ileum and 
the caecal cul-de-sac there was no mortality if the 
animals were not operated upon or were operated 
upon 3 hours after perforation; but there were fatal 
results when the animals were operated upon 24 
hours after perforation, and the mortality increased 
when the time of operation was extended up to 48 
hours. 

The practical conclusion which the author 
draws from his experimental results is that, owing 
to the probability of spontaneous recovery in per- 
forations of the gastro-intestinal tracts, and that 
the technical difficulties of surgical intervention re- 
quire a very skillful surgeon and intelligent assist- 
ants, intervention should be avoided, except when it 
is certain that the perforation involves the colon 
or duodenum, in which event it must be made as it 
offers the only chance to save the patient's life. 

W. A. Brennan. 

Smithies, F.: The Etiologic Relationship Existing 

Between Gastric Ulcer and Gastric Cancer; 

an Analysis of 921 Cases of Gastric Cancer and 

500 Cases of Gastric Ulcer. Lancd-Clin., igi6, 

cxv, 203. 

The author discusses the etiologic relationship 

deduced from the comparative study of 921 cases of 

operatively-proved gastric cancer with 500 opera- 

tively demonstrated cases of benign gastric ulcer. 

Experimentally gastric ulcer has been produced 
by bacterial activity as well as by their toxins, also by 
cutaneous burns, poisons of metabolic origin, cor- 
rosive poison, as well as by alterations in the cir- 
culation of the stomach. The life history of any 
gastric ulcer cannot be predicted. Most of them 
have a tendency to spontaneous healing, as is 
shown by the finding of healed scars at the autopsy 
table or at operation. The time for the develop- 
ment of ulcer is not definitely determined, and 
while huge calloused ulcers may form in a few weeks, 
the superficial erosions may exist for years. No 
experimental method has ever been devised that 
causes gastric ulcer in an animal to become malig- 
nant. Thus in the human there is still some 
unknown factor at work. Of the gastric cancer 
cases 65 per cent were preceded by dyspeptic symp- 
toms, apparently of the benign type as seen in 
ulcer, so closely simulating them that differentia- 



tion was impossible. McCarthy's account of 
280 resected gastric ulcers is quoted, in which 
clinically there was no hint of malignancy, yet 
63 per cent of these cases showed evidences of a 
typical cell at their edges. Still this does not prove 
that these ulcers were ever benign. In quoting 
the general opinions in regard to the percentage of 
gastric cancer preceded by ulcer, the figures vary 
from Fenwick's 3 per cent to Sapeska's 90 per cent. 
Duodenal ulcer occurs in the proportion of 2.45 
to I of gastric ulcer, yet cancer of the duodenum is 
of very infrequent occurrence. Whether this 
relation is influenced by the different chemical 
reactions of the intestinal juices, or by the more 
rapid progress of the food through the duodenum, 
it is impossible to say. The duodenum seems to have 
some inherent protective mechanism against malig- 
nancy, however. Cancer of the stomach rarely 
involves the duodenum by extension; whereas ulcer 
of the duodenum extending through the pylorus not 
infrequently shows malignant changes on the 
gastric side. Apparently gastro-enterostomy, in 
case of gastric cancer, has a tendency to prolong the 
disease and lessen its virulence. Evidence strongly 
supporting the pathologic proof that malignancy 
may develop in gastric ulcers, is furnished by the his- 
tologic observations of all degrees of hyperplasia, 
benign, intermediate, and malignant, in sections, 
through difterent points of excised ulcers. Gastric 
ulcer usually causes death within a year of the onset 
of symptoms, unless there is surgical intervention. 
This varies, however, as one individual may be 
overcome in a few weeks, while another may live for 
several years. 

Smithies divides his cancer cases into two groups: 
(i) those in which there was chronic dyspeptic 
disturbance, clinically benign, followed by an 
ailment which appeared clinically malignant from 
its start: (2) cases in which the disease was con- 
tinuous and progressively downward, clinically 
malignant, with no previous gastric trouble. The 
first group shows the possibility of separating 
clinically the benign from the malignant. The pro- 
portion was 56.4 per cent in group one; 39.1 per 
cent in group two. Cases in group two were clini- 
cally malignant from the start, the average duration 
of symptoms being 7 . 6 months. These cases 
may have resulted from cases previously benign, 
unnoticed. The location in the stomach of cancers 
and ulcers, practically identical, is quite suggestive 
of the relationship of their origin. Neither clini- 
cally, microscopically, nor experimentally, is it 
possible to prove that cancer arises from ulcer. 
However, from various corelated standpoints, their 
coexistence is very suggestive of ulcer shading off 
into cancer. H. G. Sloan. 

Durante, L. : The Trophic Element in the Origin of 
Gastric Ulcer. Surg., Gyncc. 6° Obst., 1916, x.xii, 
399- 
The methods by which gastric ulcers have been 

produced experimentally are reviewed. Durante 



GENERAL SURGERY — SURGERY OF THE ABDOMEN 



141 



states that in order to obtain a clean experiment a 
disturbance of secretion, circulation, or innervation 
must be created, (i) The pathogenic value of a 
gastric juice is not clear. Hydrochloric acid by 
mouth and hypotonic salt solution have both given 
negative results. (2) Obstruction of the larger 
gastric arteries has failed, but emboli blocking the 
smaller vessels has given satisfactory results. 
Ulcers thus produced are replicas of acute ulcers in 
man and heal readily. (3) The sympathetic nerve 
controls the vasomotor nerves of the stomach, and 
it is also the trophic nerve. 

Dalla Vedova gives the only description of arti- 
ficial ulcers presenting features of chronicity pro- 
duced by disturbed innervation. His experiments 
are made through transperitoneal operation and 
are open to criticism. Durante, in order to defend 
his experiments, chose the lumbar route in operat- 
ing. The results are as follows: (i) No lesion re- 
sults after resection of the major splanchnic. (2) 
Resection or ligation of the median splanchnic in- 
variably caused haemorrhagic and non-haemor- 
rhagic lesion. (3) Resection of the minor splanchnic 
occasionally produced a slight haemorrhagic lesion. 
(4) Resection of the median and minor splanchnics 
caused lesions. (5) Resection of the three splanch- 
nics produced lesions. (6) In resection or ligation 
of the median splanchnic, haemorrhage and intense 
congestion were seen in the adrenal of the cor- 
responding side, but these changes did not occur 
when the major splanchnic alone was resected. 

The haemorrhagic lesions appear to be due to a 
minute lesion in a blood-vessel of the muscularis 
mucosae. The haemorrhagic area is conical, its 
base coincident with the surface of the mucous mem- 
brane. The non-haemorrhagic areas are small, 
conical, pale, and few in number. These mark the 
first stage of a specific kind of ulcer which presents 
the characteristic features of true chronicity. Dis- 
turbed innervation will suffice to create lesions pre- 
senting the characteristics of acute and chronic 
ulcer in man. As both forms are found in the same 
region of the same stomach, there is reason to assume 
that time does not play a paramount part in the 
process. Neither can the size be responsible for 
its insufficient healing. Overstimulation, rather 
than insufficient innervation, of the middle splanch- 
nic seems to be the principal cause of haemorrhagic 
gastric ulcer. The non-haemorrhagic lesion is a 
spastic disturbance due to the action of adrenalin. 
This action causes rupture of the blood-vessels at 
some points, spastic contraction in others. Trophic 
disturbances are not sufficient to cause ulceration 
unless accompanied by vascular disturbances. It 
does not seem logical to assume that gastric ulcer 
should be caused by a single etiologic factor since 
it is associated with the most widely divergent 
clinical syndromes, but in the majority of cases the 
ulcer appears with no apparent relation to other 
diseases. Ulcer may be produced by any agent 
capable of damaging the sympathetic nervous sys- 
tem, as it is on the integrity of this system, which 



controls circulation, secretion, and profound sensi- 
bility in the stomach, that the very life of the gastric 
cell may be said to depend. The theory of '' trophic 
ulcer" must be taken in this sense. 

Andresen, F. R. : The Treatment of Gastric Ulcer, 
with Especial Reference to Its Etiology as an 
Infective Process. Med. Rec, 1916, Ixxxix, 457. 

After a preamble in which he briefly reviews 
the experimental evidence that gastric ulcer is the 
result of an infective process, the author proceeds to 
a consideration of the rational treatment of ulcer. 

In simple ulcer, acute or chronic, as an infective 
process, the indications for treatment are: (i) to 
remove the cause of the infection; (2) to procure 
rest for the infected part; and (3) to aid nature in its 
efforts to overcome the infection and repair the 
damage done. Gastric atony, gastroptosis, intes- 
tinal kinks, improper habits of diet, and occupa- 
tions causing continued pressure against the epigas- 
trium are sought for as possible contributing causes 
and corrected if found. The most important point, 
however, is the search for and elimination of all 
sources of chronic infection such as septic foci in 
teeth, nose, throat, etc., which the author considers 
the most frequent cause of relapse. In a series of 
96 cases infections of the teeth and gums were 
present in 81 per cent, of the nasopharynx and 
accessory sinuses in 15.6 per cent; other infections 
were found in 3.6 per cent. In practically all 
cases the streptococcus viridans was isolated in 
pure culture. 

The author regards excision of an uncomplicated 
ulcer as indicated only after prolonged and ade- 
quate medicinal treatment has done no good. Sim- 
ple gastro-enterostomy is regarded as a palliative 
method which must be followed by months of strict 
ulcer diet to afford permanent relief. If operation 
is indicated, excision of the ulcer is the operation of 
choice. 

Rest of the affected part is obtained by proper 
diet, rest in bed, demulcent coating of the ulcer, 
neutralization of the hyperacidity, by the use of 
quieting drugs and proper attention to the evacua- 
tion of the intestinal tract. Each method is dis- 
cussed with more or less detail. The author con- 
demns duodenal feeding on the ground that the 
tube, a foreign body, will cause greater excitability 
of the stomach. 

To aid nature in its efforts to overcome the in- 
fection and to institute reparative processes, the 
author places the greatest reliance upon autogenous 
vaccines which are prepared from the foci of infec- 
tion. In from six to twenty-four hours after the 
first injection there is, as a rule, a distinct general 
reaction with an exacerbation of the ulcer symptoms 
followed by a marked improvement. Three case 
histories are; cited to illustrate the author's methods 
more explicitly. 

The complications of gastric ulcer are haemor- 
rhage, perforation, disturbances of motility, and 
carcinomatous degeneration. With haemorrhage, 



142 



INTERNATIONAL ABSTRACT OF SURGERY 



rest in bed is imperative until the haemorrhage has 
ceased. Horse serum subcutaneously is indicated 
in severe cases, while gelatin by mouth and calcium 
by mouth or rectum are the safest routine agents. 
Rectal feeding is of doubtful value, but dextrose or 
lactose solutions should be tried when it is neces- 
sary to prohibit all food by mouth for some time. 
Severe haemorrhages which threaten the life of the 
patient require opening of the stomach and suture 
of the bleeding point, or preferably excision of the 
ulcer. 

Perforation, whether acute or chronic, requires 
operation as soon as the diagnosis is made. Severe 
disturbances of motility likewise require suitable 
operation. Carcinomatous degeneration requires 
operation as early as recognized or even when only 
suspected. E. Fischel. 

Delia Torre, P.: Total Endogastrectomy (L'abla- 
zione totale della mucosa gastrica). Clin, chir., 
Milano, 1916, No. i, 29. 

The author's conclusions relative to the technique 
employed and the results, macro- and microscopical, 
of recent experimental researches are as follows: 

1. The total ablation of the gastric mucosa is 
highly possible, making recourse to separation. 

2. The scraping carried on at the cardiac and 
pyloric orifices, in order to guarantee total abla- 
tion, should not in any case attack too deeply the 
tunica muscularis in order that the danger of cica- 
tricial stenosis may be avoided, following the 
reversing of the bleeding surface. 

3. Total, subtotal, or partial extirpation of the 
gastric mucosa is never followed by necrosis with 
subsequent perforation of the gastric wall. 

4. The regeneration of the gastric mucosa, pro- 
ceeding relatively rapid from the germinating centers 
represented by the stratum glandularis of the 
oesophagus and duodenum, terminates by re- 
generation shortly of the entire internal surface of 
the stomach, more or less accentuated, in a limited 
space of time, differing in various animals. 

5. The regenerated mucosa shows a perfectly 
normal histologic structure. 

6. The secreting function of the stomach does not 
appear at one time, but increases with the regenera- 
tion of the gastric mucosa. Traces of free HCl 
in the gastric contents were not found even as late 
as eight months after the operation. 

Raoul L. Vioran. 

Lewisohn, R.: Pyloric Exclusion, an Experimental 
and Clinical Study. Surg., Gynec. &° ObsL, 1916, 
xxii, 379. 

Up to a few years ago simple gastro-enterostomy 
was considered the method of choice for the treat- 
ment of gastric and duodenal ulcers.- Most sur- 
geons, however, now agree that pyloric exclusion in 
some form ought to be added to this procedure in 
order to permanently cure pyloric and duodenal 
ulcers. It is a well known fact that simple gastro- 



enterostomy does not prevent the food from passing 
through the pylorus and over the ulcerated area. 

The author states that there are five different 
methods of pyloric exclusion but that none of them, 
with the exception of Eiselsberg's method, assures 
a permanent exclusion. He reports experiments 
with a modified Biondi method. This modification 
ensures permanent exclusion. The technique, how- 
ever, is too difficult, and the method therefore should 
not be applied in clinical surgery. He shows the 
stomach of a dog operated upon according to the 
Biondi method and killed three months after opera- 
tion. The pylorus was wide open and scarcely any 
sign of surgical interference could be seen. 

He further demonstrates a human pylorus which 
he resected in July, 1915. This patient had under- 
gone a gastro-enterostomy and pyloric exclusion 
with the string method eighteen months previ- 
ously. The pylorus was patent, admitting the 
little finger, the stitch was still in situ. He con- 
cludes that the clinical results are just as good in 
using the most simple method (exclusion stitch), 
as in the use of the most complicated method 
(Eiselsberg) . Though the exclusion stitch does not 
ensure a permanent exclusion of the pylorus, it en- 
sures a temporary one and thus effects the healing 
of the ulcer. 

The author formulates his conclusions as follows: 

1. With the exception of Eiselsberg's unilateral 
exclusion and the modified Biondi method, none of 
the different methods of "exclusion" guarantees a 
permanent occlusion of the pylorus. 

2. An absolute, though temporary, "exclusion" 
of the pylorus provides for a permanent cure of 
pyloric and duodenal ulcers. 

3. The most simple method from a technical 
standpoint is the "exclusion" stitch (Kelling-Berg- 
Cackovic). This stitch should be used in preference 
to the more complicated methods (Wilms, Par- 
lavecchio, Biondi). 

4. The Eiselsberg method and the modification 
of the Biondi method, though guaranteeing a 
permanent "exclusion," are technically too com- 
plicated and should not be used. 

5. The clinical results are just as good in using 
the most simple method (exclusion stitch) as in the 
use of the most complicated method (Eiselsberg). 
The exclusion stitch can therefore be considered as 
the method of choice for the treatment of pyloric 
and duodenal ulcers. 

Jefferson, G., and Flumerfelt, G. : The Anatomical 
and Physiological Subdivisions of the Duode- 
num, with a Note upon the Pathogenesis of 
Ulcer. Ann. Surg., Phila., 1916, Ixiii, 318. 

The subdivisions of the duodenum as commonly 
given in anatomical textbooks are very artificial 
and are neither physiological nor embryological. 
The use of these subdivisions as the basis of classi- 
fication of lesions of the duodenum leads to much 
inaccuracy and confusion in interpreting diseases 
of this portion of the alimentary tract. The au- 



GENERAL SURGERY — SURGERY OF THE ABDOMEN 



143 



thors believe that it would be much better to divide 
the duodenum into two parts, cephalad and caudad 
to the bile-papilla (papilla major Santorini). These 
parts are called "supra-" and "infrapapillary." 
This classification is not only developmentally cor- 
rect but stands the test of pathology. 

An examination of the records of 496 definite cases 
of duodenal ulcer shows that they are very common 
in the acid suprapapillary portion; that their 
incidence decreases as the papilla is neared; and that 
they are extremely rare in the alkaline "infrapapil- 
lary" region (only one case of the series). 

Statistics show that duodenal carcinoma is com- 
monest in the second part, but this is due to the 
inclusion of vaterian cancers in the total of duodenal 
neoplasms. When these have been subtracted 
carcinoma seems to be more common in the supra- 
papillary region than elsewhere in the duodenum. 
This is probably due to the greater incidence of 
chronic ulceration in the former, although cancer 
following duodenal ulcer is notably rare. 

Gatewood. 

Dodge, G. E.: Cystic Dilatation of the Vemiiforin 
Appendix. Ann. Surg., Phila., 1916, Ixiii, 334. 

From a review of 142 cases of cystic dilatation of 
the appendix, the author is led to believe that the 
condition is relatively rare, and that true hydrops 
forms less than 9 per cent of all appendiceal cysts. 
From the evidence obtained from the collected cases, 
it seems that these cysts are essentially retention 
cysts of inflammatory origin. The lumen of the 
appendix, while often completely or partially 
obliterated, may be patent. The condition runs 
by no means a symptomless course; symptoms being 
present in 24 per cent of all cases, and in at least 51 
per cent of operative cases. 

The contents of some of these cysts when im- 
planted upon the peritoneal surface are capable of 
producing the condition known as pseudomyxoma 
peritonei. Some of the appendiceal cysts present 
structural and clinical characters that seem to ally 
them with adenocystomata. Carcinomatous 
changes have been occasionally observed, although 
some cases reported as carcinoma have lacked the 
clinical aspects of malignancy. The author fur- 
nishes a table with the literature of the 142 cases 
which he has been able to find and includes one case 
of his own. Gatewood. 

Wachenheim, F. L. : A Contribution to the Diagno- 
sis of Appendicitis in Childhood. Arch. 

Pediatrics, 19 16, xxxiii, 197. 

The subjective sensations available in intelligent 
children are a valuable aid in diagnosis. High 
palpation of the right iliac fossa, per rectum, elicits 
tenderness and pain in the McBurney region when 
appendicitis is present, never under normal condi- 
tions. To determine this point it is necessary to 
observe certain precautions. In the first place, the 
confidence of the little patient must be gained, 



assuring him that the procedure will not be distress- 
ing. Secondly, the examining finger must be in- 
troduced quite painlessly. This can always be done 
if patience is exercised. The ordinary rectal ex- 
amination is far too often conducted brutally, 
causing the patient considerable pain and alarm. 

The valuable diagnostic point consists in the fact 
that the patient complains of no discomfort until 
the introduced finger reaches the right iliac fossa, 
when the child complains of a sharp pain in the 
neighborhood of McBurney's point. 

Edward L. Cornell. 

Soper, H. W.: Polyposis of the Colon. Am. J. M. 

Sc, 1916, cli, 405. 

In 1907 Doering collected 52 cases from the litera- 
ture and the author now adds 8 new ones, reporting 
one of his own in which the entire colon was suc- 
cessfully resected. 

These 61 cases show that the growths are most 
frequent in children; 43 per cent were adenocarci- 
noma, usually of the rectum, sigmoid, or splenic 
flexure; the small intestine is rarely involved, and 
there is a family tendency. 

Esser, Carroll, Lindner, and Lilienthal report 
cases successfully operated on. 

The case reported was that of a male, aged eight, 
with a history of diarrhoea since infancy. Two 
years previous, anal prolapsus was followed by the 
removal of a small polyp from the first valve of 
Hanston. At the same time a small polyp was re- 
moved from the cheek — both were simple adenoma. 
Two months later two polypi were removed by 
snare, three inches from the anal margin. Again, 
sixteen months later four growths five inches from 
the anal margin were removed in like manner. 
During the entire time occult blood persisted in 
the faeces and colonic involvement was diagnosed. 

Abdominal section was done with removal of 
the entire colon, the anastamosis being made by a 
Murphy button. Rapid recovery followed and one 
year later sigmoidoscopic examinations showed 
no recurrence, but considerable dilatation of the 
rectum and sigmoid. The pathological report was 
benign adenoma. P. M. Chase. 



LIVER, PANCREAS, AND SPLEEN 

Ugaz, R. I.: Retrograde Cholecystectomy for 
Chronic Calculous Cholecystitis in a Man of 

78 (Colecistectomia retrograda par colecistitis 
cronica calculosa en un hombre de 78 anos). Cron. 
med., 1916, xxxiii, 66. 

In Deaver's report of 159 interventions for 
cholecystitis up to 1914, the greatest age among the 
operated was 70 years, and the author has not found 
this age limit exceeded in a research through the 
literature of the subject. 

His own case was in a man of 78, who, after under- 
going medical treatment for more than twelve 
months in a hospital without relief, was finally 



144 



INTERNATIONAL ABSTRACT OF SURGERY 



operated upon. The cholecystectomy was done 
following the classic procedure. On the eighth day 
there was a slight recurrence of biliary symptoms 
which passed away, and recovery was fully estab- 
lished after thirty days. W. A. Brennan. 

Mitchell, W. T., Jr., and Stifel, R. E. : The Pressure 
of Bile Secretion During Chronic Obstruction 
of the Common Bile-Duct. Bull. Johns Hopkins 
Hosp., 1916, xxvii, 78. 

In animals with experimental obstruction of the 
common bile-duct the authors have frequently ob- 
served that a rupture of the bile passages often oc- 
curred with escape of bile into the peritoneal cavity. 
They therefore undertook a series of experiments 
to ascertain whether, following an obstruction, 
there was a rise in pressure within the bile passages 
from day to day. 

Under aseptic conditions the common duct was 
ligated with silk thread as near the duodenum as 
possible, and the animals were allowed to recover 
and given food and water, and then from time to 
time pressure within the bile duct was recorded. In 
12 cats the pressure ranged from a minimum of 236 
to a maximum of 360 mm. with a mean pressure of 
278 mm. The authors found that the pressure re- 
mained remarkably constant, not rising or falling 
more than a few millimeters during several hours. 
They obtained no uniform variation in bile pressure 
by the stimulation of nerves. Electrical stimula- 
tion of the vagi gave a rise of 4 or 5 mm. Their 
experiments therefore showed that in chronic ob- 
struction of the common bile-duct the pressure rose 
no higher than in acute obstructions. It might be 
even higher at the end of three hours than at the 
end of three days, but probably there would be little 
variation. They found that there were individual 
variations which they did not attempt to explain, 
but there was no relation between the pressure and 
the weight of the animal. 

The authors therefore feel safe in assuming that 
the pressure in the bile-duct rises sharply during the 
first three hours after obstruction. After this time 
it remains fairly constant, but is the result of two 
factors: (i) secretion by the hepatic epithelium, 
(2) absorption by way of the hepatic veins. 

George E. Beilby. 

Jablons, B.: Concretions of the Spleen. Calif. St. 
J . Med., 1916, xiv, 103. 

Concretions of the spleen are very rare, in fact 
only two cases were found in the literature by the 
author. All stones have been found accidentally at 
autopsy. Several theories are advanced as to their 
origin: (i) old calcified tubercles; (2) calcified 
hydatid cysts; (3) calcified thrombi. 

The author's case was that of an old man who died 
subsequent to an operation for carcinoma of the 
penis. The post-mortem was not remarkable except 
that it showed several concretions near the hilus of 
the spleen. These were partially infiltrated with 



connective tissue. The conclusion of the author 
was that they were phleboliths. J. H. Skiles. 

Silvestrini, L.: Extirpation of the Spleen in the 
Pathology of the Liver and the Blood (Estir- 
pazione della milza nella patologia del fegato e 
del sangue). Riforma med., 1916, xxxii, 266. 

Some morbid conditions of the blood and of the 
liver owe their origin to alterations developing pri- 
marily in the spleen and which thence diffuse secon- 
darily to the liver and to the blood; in others spleno- 
pathy figures as the prevalent factor in the morbid 
syndrome. 

Attempts have therefore been made by various 
therapeutic means to act on the spleen directly and 
destroy toxic processes in their inception; but the 
failure to accomplish this by medical agents has 
led to the use of more radical measures. There is no 
agreement as to the exact value of splenectomy, as 
the functional effects of the spleen on the organism 
are not definitely known. 

Silvestrini has made a number of animal experi- 
ments to determine the effects of splenectomy. 
These experiments, made on rabbits, show that the 
age of the animal and the conditions of life effect 
the results. 

Splenectomy in rabbits produces: 

1. A diminution of erythrocytes if the animals 
are very young; an increase if they are adult. 

2. A diminution of the haemoglobin contents if 
the animals are adult. 

3. An increase of the globular resistance of the 
erythrocytes whatever the animal's age may be, but 
this returns to normal after about eight months. 

With regard to the relations which exist between 
the spleen and the other organs, Silvestrini's re- 
searches have resulted in these conclusions: 

1. Extirpation of the spleen is well tolerated in 
rabbits and does not cause any alterations which 
are macroscopically appreciable in the different 
organs of the body. However, such an animal while 
it shows greed for food does not show a develop- 
ment compatible with its alimentation. 

2. After extirpation of the spleen, there are no 
immediate manifestations in the liver. Later there 
is observed a lymphatic hyperplasia first about the 
portal vessels, then in the hepatic lobes. There 
is an increase in the weight of the liver some time 
after splenectomy. Later still there is a slight 
alteration in the hepatic cells, but the alteration 
does not appear to be equal in the different lobes, 
which is not in agreement with Glenard's hypothesis 
that there is a functional anatomic automatism in 
the two hepatic lobes. 

The author applies these results to the surgical 
practice of splenectomy. He thinks this operation is 
indicated in splenic anaemia (Banti's disease) , 
chronic haemolytic splenomegalic icterus, haemolytic 
anaemia, early primitive tuberculosis of the spleen, 
and leukaemia. In the case of pernicious anaemia 
and infantile splenomegalic anaemia the value of 
splenectomy is doubtful, while in kala-azar and allied 
conditions it is contra-indicated. W. A. Brennan. 



GENERAL SURGERY — SURGERY OF THE EXTREMITIES 



145 



SURGERY OF THE EXTREMITIES 



DISEASES OF THE BONES, JOINTS, MUSCLES, 

TENDONS. CONDITIONS COMMONLY 

FOUND IN THE EXTREMITIES 

Horwitz, A. E. : The Changed Character of Later 
Lesions Occurring in So-called Healed Tuber- 
culous Joints. J. Mo. St. M. Ass., 1916, xiii, 114. 

In all the cases observed by the author, the find- 
ings were constant and as follows: At an early age 
the patient suffered from a typical attack of tuber- 
culous disease. The treatment was in accordance. 
A cure resulted in due time. A period of freedom 
existed for a number of years, ranging from five to 
ten. Pain began to recur gradually. This was 
noted upon use of the part only. There was no 
pain at night or when at rest. The pain was great- 
est on first use of the joint, decreasing as motion or 
exercise increased. The same objective signs and 
findings were noted. Motions of the joint were 
limited when first manipulated. Further manip- 
ulations increased the range of motion and dimin- 
ished the pain. Slight tenderness existed. Re- 
ferred pain was noted. The roentgen ray showed 
the old necrosed bone with new tissue replacing it. 
With these findings the treatment naturally con- 
sisted in manipulations and massage, the reverse to 
that employed in the original condition. 

Edward L. Cornell. 

Silver, D. : The Role of Visceroptosis in the Etiology 
of Arthritis Deformans. Tr. Am. Orth. Ass., 
Washington, 1916, May. 

After outlining the present understanding of vis- 
ceroptosis and its influence on alimentary toxaemia 
and emphasizing the extremely complex etiology 
of arthritis deformans, the author assumes that in 
many cases in v/hich the two coexist the visceropto- 
sis is of the secondary acquired type; further, that 
in any case in which there is a primary visceropto- 
sis of sufficient degree to interfere with function it 
necessarily acts as a predisposing factor in the 
production of the arthritis and may be the deciding 
factor. 

The questions left for discussion are: (i) how 
frequently alimentary toxsemia may act as such a 
deciding factor, and (2) whether the toxins, bacterial 
or chemical, thus enabled to enter the circulation 
may directly induce joint change. 

The laboratory and clinical evidence bearing 
upon the nature of the toxins in alimentary toxaemia 
is reviewed and the published cases in which opera- 
tions for the relief of intestinal absorption in arthri- 
tis deformans have been performed are analyzed. 
From this study the author concludes: "It seems 
to have been demonstrated that the active agent in 
arthritis deformans may enter through the intestinal 
tract. This active agent is undoubtedly bacterial, 
probably most commonly streptococcic, and the 



intestinal mucosa is thus to be regarded as one of a 
number of mucous surfaces through which infection 
may enter the system. Through the production of 
stasis and probably also through its influence on 
glandular secretions, visceroptosis acts to cause in- 
creased intestinal infection and so favor systemic 
invasion; thus in an individual with lessened joint 
resistance it may be the deciding factor in the de- 
velopment of arthritis. How frequently arthritis 
develops in visceroptotic subjects and what the 
proportion is between the number of cases of 
arthritis due to this cause and that arising from 
other intestinal affections cannot now be stated. 

Boehme, G. P., Jr.: Plasterers' Corns and Bunions. 

Med. Rec, 1916, Ixxxix, 560. 

A peculiar deformity found in plasterers' hands is 
caused by the use of the "hawk," a flat board with a 
central handle underneath it on which the plaster 
is held. Clinically the condition is a large bursa, 
like a typical bunion, found over the external aspect 
of the metacarpophalangeal joint of the thumb, 
varying in size from a quarter dollar to a fifty-cent 
piece. A smaller bursa is often found over the same 
joint of the index-finger. Over the first inter- 
phalangeal joint of the index-finger and the corre- 
sponding joint of the thumb are two hard callous 
areas or corns. 

The etiology of the condition is found in the 
manner in which the "hawk" is held, the central 
handle being grasped in the left hand, the board 
resting principally on the metacarpophalangeal 
joints and the flat surfaces of th§ index-finger and 
the thumb. The weight of six to eight pounds is 
thus borne for about eight hours a day to which is 
added the constant irritation of the board as it is 
rotated as the plaster is gradually removed. The 
treatment is prophylactic directed to the removal of 
the cause, toward this end the author having de- 
vised a new form of "hawk" which consists of a 
board with a handle revolving within a cylinder thus 
doing away with the constant friction. For early 
cases local soothing applications are advised with 
later use of the new form of "hawk." For long 
standing cases, inflamed bursas are treated like those 
found elsewhere in the body. Calluses may be 
removed by caustics or any salicylic salve. 

R. S. Bromer. 

FRACTURES AND DISLOCATIONS 

Taylor, G. : Some Notes on War Fractures. Prac- 
titioner, Lend., 1916, xcvi, 244. 

The author gives a dissertation on fractures 
occurring in warfare. The surgeons have been 
guided by the principles laid down by the British 
Medical Association Committee on the treatment 
of fractures, which are somewhat as follows: 



146 



INTERNATIONAL ABSTRACT OF SURGERY 



1. In cases treated by non-operative methods, 
the older the patient, the worse the result. 

2. In cases treated by immediate operation, the 
deleterious influence of age upon the functional 
result is less marked. 

3. In nearly all age groups, the operative cases 
show a higher percentage of good results than non- 
operative cases. 

4. Although the functional result may be good 
with an indifferent anatomical result, yet the most 
certain way to obtain a good functional result is 
to secure good anatomical alignment. 

5. Operative measures are not to be regarded 
as a method to be employed in consequence of the 
failure of non-operative measures, for the results 
of secondary operations compare very unfavorably 
with those undertaken immediately after the injury; 
in order to secure the best results of operation, this 
should be resorted to as soon after the accident as 
practicable. 

6. The method is not to be undertaken except 
by such as have skill and experience in surgery, 
and the surroundings must be such as to ensure 
asepsis. 

Fractures in the neighborhood of joints, and 
fractures complicated by nerve injuries, are almost 
always submitted to operation. Lane's technique 
was employed. The author condemns the treat- 
ment of compound fractures which are infected by 
plating. In case shortening should demand plating, 
it is wise to allow several weeks to elapse after the 
wound has healed before operation is undertaken. 
If the application of extension and splints does not 
give a good anatomical and functional result, he 
advocates open operation. He thinks it is wise in 
compound, comminuted fractures in the neighbor- 
hood of joints, to remove adjacent fragments of 
bones when necessary. He quotes Sir John Glen 
Sutton in advocating such treatment in gunshot 
wounds of the upper end of the humerus. Amputa- 
tions are undertaken only when general septicaemia 
threatens life. Death has been the usual outcome 
when rapidly spreading gangrene has followed 
ligation of the femoral artery because of haem- 
orrhage, in compound fractures of the thigh. He 
has gained a very favorable impression of the use- 
fullness of sulphur and glycerine emulsion as an 
antiseptic in infective cases. H. G. Sloan. 

Lemon, C. H.: Is It Possible to Obtain Bony Union 
in Intracapsular Fractures of the Hip- Joint? 

St. Paul M. J., 1916, xviii, 86. 

The author notes that fracture of the neck of 
the femur is a comparatively rare occurrence, and in 
proportion to the population it occurs more fre- 
quently in rural districts than in the city. He 
states that the family physician is not as a rule 
sufficiently informed as to the possibilities of treat- 
ment in this class of cases and does not inform the 
patient in time as to what may be accomplished, 
and Lemon is inclined to recommend that these cases 
be placed in the hands of a specialist in large clinics. 



He laments the confusion of thought on this subject 
and that the average medical man does not know 
the difference between an intra- and an extracapsular 
fracture clinically. The teachings of Sir Astley 
Cooper that intracapsular fractures of the femur 
were incapable of bony repair, excepting in the cases 
where no actual separation of fragments had oc- 
curred on account of the untorn periosteum of the 
neck. Lemon believes untrue. Portions of the 
Hunterian Lecture of E. W. Hey Groves, for the 
year 19 14, is reviewed and the author criticizes the 
experiments undertaken, because in the experi- 
ments a condition was created that never occurs in 
simple fractures. A fundamental law in the healing 
of fractures is that bony apposition of the frag- 
ments must be obtained if callus is to be obtained. 
The author has treated about 50 cases of fracture 
of the hip-joint during the last fifteen years, ac- 
cording to a definite theory, with uniform success. 
His central thought has been approximation of the 
fragments, his experience being that where the frag- 
ments were approximated and held immovable from 
two to four months in a well applied spica dressing 
the patients suffered no pain. They had no bed- 
sores and they ultimately walked without a crutch 
or a cane, and, excepting in those cases that were 
nailed, they walked without a limp. In view of 
this experience he is unable to understand the at- 
titude of some leading fracture experts, in persisting 
in the statement that a functional result is all that 
can be hoped for in the majority of these cases. 
Lemon believes that what is possible in the treat- 
ment of other fractures in joints is possible in the 
treatment of fractures of the hip-joint. He be- 
lieves in the proper application of the Whitman 
method, emphasizing the correct manner of apply- 
ing the plaster-of-Paris spica as being of very great 
importance in the success of the treatment. This 
he believes will prevent failure in from 90 to 95 
per cent of the cases, and is the treatment recom- 
mended by him. Emil C. Robitshek. 

Wight, J. S.: Methods of Treating Oblique Frac- 
ture of the Femur. Am. J. Surg., 1916, xxx, 86. 

Wight advises waiting five or six days before un- 
dertaking the open reduction method. He secures 
the oblique fragments with screws and removes all 
mechanical devices after they have served their 
purpose, as they are foreign bodies and tend to cause 
irritation. The best and most accurate method of 
extension is by means of the Steinmann pin through 
the bone, so the pull will be applied directly to the 
distal fragment. R. B. Cofield. 

Hungtington, T. W. : Fracture Records; a National 
Effort Toward Standardization. Northwest Med. , 
1916, XV, 114. 

The author emphasizes the absence of any com- 
plete fracture records either in hospital or in private 
work and refers to the important relation of the 
recent legislation of compensation laws to the end- 
result of fracture treatment. He gives the "frac- 



GENERAL SURGERY — SURGERY OF THE EXTREMITIES 



147 



ture schedule" recommended by the Committee 
on Fracture Treatment of the American Surgical 
Association and makes a plea for its adoption by 
hospitals, physicians, and insurance companies, 
in order that a more exact knowledge of the end- 
results of different methods of treatment, which 
are based upon the permanent functions of the 
affected part, may be obtained. E. B. Mumford. 

Allen, H. E. : A Plea for Conservative Treatment of 
Fractures. Northwest Med., 191 6, xv, iii. 

Allen feels that there is a conservative field for 
the treatment of fractures and that a great many 
open operations are unnecessary and expose the 
patient to infections. He emphasizes the fact that 
the alignment is more important than a perfect 
end-to-end apposition. 

The use of Lane plates in old ununited fractures 
and deformities is condemned and the bone-graft 
is advised instead. The author feels that the in- 
dication for operation in a fracture is the inability 
to obtain apposition and alignment. 

E. B. Mumford. 

Lane, A.: The Operative Treatment of Fractures 
in Warfare. Practitioner, Lond., 1916, xcvi, 231. 

Lane gives an account of fractured bones treated 
by plating, and the text is profusely illustrated with 
radiograms. 

Attention is called to the fact that fractures 
received in warfare usually show more comminution 
of the bone because of the force of the projectiles, 
in contrast to that seen in civil life. Infection 
follows more frequently because of the fact that 
bits of clothing and dirt are carried in by the pro- 
jectile. He does not advise fixation of fragments 
in compound fractures where there is infection 
immediately after the receipt of the injury. In 
case fixation may be necessary for the comfort of 
the patient, it is best to place the screws at some 
distance from the site of the fracture in order to 
avoid further rarefaction of the bone from the 
screw holes becoming secondarily infected. The 
plates now used in bone work, in connection with 
the war, are much stronger than those formerly 
used in civil practice. In case it is necessary to 
plate a compound infected fracture, it is wiser to 
allow several weeks to elapse after the injury has 
been received before operating. 

The author lays stress on his plan of putting the 
bones in alignment by means of plates where there 
has been loss of substance in the bone, after allow- 
ing for any shortening. When the ends are not in 
contact, they will regenerate enough bone to bridge 
the gap, if the effect of engorgement is taken advan- 
tage of by allowing the patient to be up with an 
ambulatory splint applied. If any septic focus 
is observed during an operation, a culture and 
vaccine should be obtained and employed at once, 
should symptoms of wound infection develop. It 
is most important that the joints which are in 
relation to the fractured bone shall be moved as 



soon as possible after operation, in order to avoid 
stififness in the joints. Being up and around, with 
an ambulatory splint, materially increases the 
amount of callus at the site of fracture. Should 
rarefying osteitis exist, it is evident that the tech- 
nique of the operator is faulty. H. G. Sloan. 

Preston, M. E. : Conservation in the Operative 
Treatment of Fractures. Colo. Med., 1916, 
xiii, 83. 

New therapeutic measures are often too readily 
taken up and as readily discarded even before their 
efficacy has been tested. Bleeding, oophorec- 
tomy, salvarsan, and sodium cacodylate are cited as 
examples. Preston urges that scientific considera- 
tion be given each new measure before it is heralded 
or condemned. 

The principal factors pointed out as necessary in 
operative treatment are exactness, proper technique, 
full appreciation of the mechanical factors, a good 
working knowledge of anatomy, and a full apprecia- 
tion of the laws of stress, strain, and leverage. 

Selected cases of fracture are suitable for surgical 
treatment. The method of fixation is largely 
determined upon by the nature of the tissue dealt 
with, whether it is compact or cancellous bone. 
Longer bone plates with the Sherman self-tapping 
screw with proper setting and only a moderate 
degree of tension give the best results. Rigid 
asepsis with due consideration of the laws of stress, 
strain, and leverage, and the nature of the tissue 
adds much to the success or failure of the operation. 

H. W. Maltby. 

Peckham, F. E.: Congenital Elevation of the 
Scapula; A New Operation? Cubitus Varus. 

Boston M. 6*5. /., 1916, clxxiv, 315. 

The operation described is new and original and 
it would seem very logical in its results. 

The author discusses briefly the cause, which 
usually is stated as being a bridge of tissue or bone 
which anchors the scapulae to the ribs or spine. The 
old operation was to remove this bridge. In the 
author's case, there was no such bridge to be found, 
and this is the type of case left untreated. The 
operation he recommends consists in removing a 
wedge of the trapezius muscle, suturing the angle 
of the scapulae to the spine low down, and uniting 
the gap left by the removal of the V-shaped wedge 
of the trapezius. 

Cubitus varus, or gunstock deformity, usually 
follows fractures of the lower end of the humerus. 

The author believes that in most cases prevention 
of rotation of the forearm is not well carried out 
and because of the rotation, the deformity occurs. 

He describes his case and illustrates the method 
of strapping the hand to prevent rotation. 

C. C. Chatterton. 

Baldwin, C. H. : Old Dislocation of the Clavicle 
in a Child. Am. J. Orth. Surg., 1916, xiv, 152. 

The patient fell down two or three stairs when 
three years old and fractured her left clavicle. 



148 



INTERNATIONAL ABSTRACT OF SURGERY 



At the age of nine, a roentgenogram showed the 
sternoclavicular articulation on the affected side 
one and one-half inches lower than the right. A 
new joint with perfect function had formed on the 
injured side. , Philip Lewin. 

SURGERY OF THE BONES, JOINTS, ETC. 

Tuffier, T. : The Functional Status of Amputation 
Stumps in War (L'etat fonctionnel des moignons 
des amputes de guerre. Arch, de med. et pharm. 
mil., Par., 1916. 

The author's purpose was to determine the best 
amputation procedures, based upon the practical 
value of the stumps obtained. The information 
was gained from 13 reports by the chiefs of the ortho- 
pedic services of the military regions and from the 
author's personal reports in the amputation ser- 
vice and ambulances at the front, comprising 2,031 
documents. 

The method of examination was uniform for all 
cases: after searching for the cause of amputation 
and that of all the consecutive accidents, a radio- 
graph was made; photographs and radiographs 
were taken of the stump both before and after 
the operation. The relative frequency of each 
variety of amputation in the present war in France 
based upon statistics from Lyons, Le Mans, Mont- 
pellier, Nantes, on 1,538 cases, as well as those of 
the Maison Blanche, comprising 1,731 cases (Maison 
Blanche is the author's clinic), is as follows: 
For the upper extremities 622 cases: 
348 arm amputations 
145 forearm amputations 
77 shoulder dislocations 
18 elbow dislocations 
34 wrist and hand dislocations 
For the lower extremities 1,109 cases: 
670 thigh amputations 
2Q7 leg amputations 
86 partial foot amputations 
29 hip dislocations 
27 knee dislocations 
Amputations, double and multiple, 45 cases, 
including one case in which both arms and both 
legs had to be amputated. Of these 45 amputations 
29 were done at one operation, 16 at two sittings. 
Adding to these figures those furnished by the 
chiefs of the orthopedic services, and classifying the 
amputations by order of frequency, the result is: 
1,063 thigh amputations 
548 leg amputations 
542 arm amputations 
251 forearm amputations 
I ID foot amputations 
125 shoulder dislocations 
58 hip dislocations 
47 knee dislocations 
41 wrist dislocations 
33 elbow dislocations 
Of the 1,731 amputations, 257, or 17.4 per cent, 
had to be operated upon twice. Interrogation of 



the 1,731 wounded brought out the fact that 279 
of them had had before from 2 to 4 successive 
amputations, 16. i per cent. After an amputation, 
a mutilated soldier has 30 out of 100 chances of 
having to submit to a new operation, considering 
that in 536 cases the first operation was not sufficient, 
or a percentage of 30.9. 

Estor's statistics are quoted showing 90.5 per 
cent good upper extremity stumps and 9.5 per cent 
bad ones; 68 per cent good thigh stumps, and 32 per 
cent bad ones; 53 per cent good leg stumps and 47 
per cent bad ones. 

Of the 279 amputations that had to be retouched 
or re-operated, the lower extremities were involved 
in 252 cases — iii hip, 141 leg — and only 27 
cases of upper extremity involvement. 

As to the choice of operative procedure, the gen- 
eral opinion and the author's personal observations 
establish the fact that the secondary operations 
that had to be performed were due to the classical 
circular incision, which procedure still has some 
staunch sustainers. War surgery, surgery in the field, 
operations day and night, clearly show that the 
circular amputation, simple and rapid, can not enter 
into the good practice of war surgery. It is difficult 
to tell in which selected cases it may be found to be 
indispensable. The general rule holds that a limb 
must be sectioned as far away from its root as 
possible; or the circular method gives in this respect 
a maximum result. The flap methods need a 
higher bony section, another disadvantage which 
can be offset by the possibility given the wounded 
to walk on the well-padded extremity of his stump, 
which gains in sluggishness to compensate what it 
loses in length. If the old imperfect circular 
method of amputation cannot be abandoned, can- 
not the results be improved by choosing the time 
of operation? Will an immediate, retarded, or late 
amputation allow of an amelioration in the condition 
of the cicatrices? Some authors are uncertain about 
it; others claim it is indifferent. The immediate 
operation eliminates the great majority of second- 
ary accidents, its greatest advantage being that 
it gives the softest cicatrices; but it is also* serious 
in certain cases, as it may help to destroy a limb 
which could probably be saved otherwise; the dis- 
advantages will decrease in proportion as new means 
of combating infection are discovered. 

As for the seat of amputation, the author believes 
in choosing a place at a distance from the focus 
proper, to avoid infection and deplorable cicatrices; 
to cut at the hip even for a crushed tibiotarsal. 
The decision as to the point of amputation is 
based upon the seat of the wound; the bone le- 
sions; the nature of the projectile; the shooting 
distance for bullet wounds; finally, the close exam- 
ination of the traumatic focus and the surrounding 
regions. 

If amputation is done secondarily, far from the 
wound above the inflamed area where gangrene is 
feared a bone segment may be removed that could 
have been saved by a primary operation and the 



GENERAL SURGERY — SURGERY OF THE EXTREMITIES 



149 



cicatrix would certainly be less favorable. Each 
case requires individual consideration. A patho- 
logical stump may be considered sufficient if it is 
not painful. 

The lesions that render an amputated limb unfit 
for an artificial limb in 30.9 per cent of cases are, 
in order of frequency: incomplete cicatrization by 
ulceration or fistula; pains spontaneous or provoked 
by the apparatus pressure; often the entities com- 
bined. Ulcerations are often caused by too short 
a flap or by a diseased bone or nerve. Very scant 
flaps are sometimes cut. Another cause of ulcera- 
tion is the lack of post-operative care. He considers 
the operative section, after an operation, as formed 
of three cylinders, one sliding into the others: 
(i) the skin; (2) the superficial muscles; (3) the deep 
muscles, fixed and adherent to the bone. These 
three planes must be mobile, sliding, and elastic. 
If in the course of cicatrization suppuration occurs, 
and this occurs nearly always in urgent amputations, 
it brings about an adhesion between the three 
cylinders; there occurs a reciprocal fixation of all 
cylinders; and elasticity becomes nil. The skin, 
fixed by its deep side, is no longer capable of cover- 
ing the entire flat and bare surface; it ends, in lucky 
cases, by epidermizing, well or poorly, but not by 
forming a cuticle over the wound, which will result 
in an interminable cicatrization or a friable cicatrix. 

To avoid the necessity for a second operation 
(the simple dissection of the cicatrix), the margins 
of the wound must be brought together rapidly, 
and handled carefully and patiently. This can be 
done by the use of sutures applied in the superficial 
muscles, or by fixing on the skin of each flap an 
agglutinant, provided with a double row of clasps, 
which exercises an elastic traction upon each wound 
lip, making a true pliable corset. In other cases 
the author has seen a sort of bracelet, made of 
a cast band, applied over the skin that borders 
the wound; this method is used mostly by the Eng- 
lish and Americans. By the aid of the X-ray the 
author found dozens of suppurating stumps, an 
index of free sequestra, superficial and deep, some 
intramedullary. If removed, an immediate cica- 
trization is obtained. The sequestra are not the 
result of a simple periosteal denudation, as formerly 
believed. The hypothesis of an infection at the 
origin must be accepted. This infection occurs as 
a rule in all war amputations. The author suggests 
therefore that periosteal denudation be carefully 
avoided, as it is unnecessary and dangerous. 

Radiographs of other cases showed an osteomye- 
litides, very frequently found in the femur. They 
are terminal or lateral. Clinically the stump re- 
mains tense, hard, painful. The removal of the 
mass eliminates such accidents. Lateral osteomye- 
litides extend 7, 8, or 10 cm. above the bony sec- 
tion, under the form of a new bony cylinder sheath- 
ing the diaphysis. They have necessitated three 
and four amputations in some cases. 

The author is not certain as to the final results 
in cases of lateral osteomyelitis. Referring to the 




Fig. I. To the left, radial osteophytis; radiocubital 
bony point: the pisiform has been omitted in the flap, with 
out interfering with the member's functions, nor with 
the application of the apparatus. 

bony tissue, which he found to be very variable, he 
discovered most frequently a condition of hyper- 
trophic osteitis, rarefied, at the same time. The 
consistency of this bone is such that the femur or 
tibia could be cut with a Farabeuf blade, and by 
two or three chisel strokes it has been possible 
to remove the diaphysis entirely. In these cases 
he obtained two processes: an infectious, and a 
trophic. The resections of these osteomyelitides are 
found to be long and tedious; the periosteal tissues 
penetrate the irregularities of the bony surface and 
adhere to its projections; the bone bleeds copiously 
and the persistence of oozing is not favorable to a 
good union. The fibrous cicatricial parts must be 
resected or freed, and the cellular tissue brought 
back to its normal suppleness, allowing the skin 
to assume a normal surface. To avoid such accident 
the author insists upon the early disinfection of the 
wounds, which is the first principle in the treat- 
ment of all war wounds. 

A condition of true ergot is also extremely fre- 



ISO 



INTERNATIONAL ABSTRACT OF SURGERY 







Fig. 2 . On the lower left is shown an example of osteomy- 
elitis with a central sequestrum, fistula, and ulceration of 
the hip stump. The section shows the old diaphysis nec- 
rosed, enclosed in an incomplete circle of osteomyelitis of 
new bone. To the right is shown a section of the preceding 
section, showing that there is not only a necrosis of the 
diaphysis, but also a series of other isolated sequestrae. 

quent, especially in the hip; rarely in the leg and fore- 
arm. In the femur they lodge at the level of its 
posterior and internal parts, on the rough line. 
They are discernible about one month after ampu- 
tation, and are from 2 to 6 cm. long, varying in 
form. Radiographed, they appear like an opaque 
tissue, and not spongy as the common osteomyeli- 
tides look. They are easily recognized and are 
frequently indolent and interfere little with the 
prosthesis. Surgeons are warned to redouble their 



prudence and attention, and they should watch 
not only the section of the rough line, but also the 
periosteal denudation at this level. An amputation 
of the hip should never be terminated before the 
condition of the periosteum of the posterior and 
internal parts of the femur is investigated. 

Neuritic pains reveal two causes easily distin- 
guished by the seat of their maximum intensity. A 
radiograph may show a normal bone, yet the stump 
may be painful. The pain is usually found over the 
cicatrix, and can be elicited by pressure; also a nerve 
stretched upon a bone may produce the pain; the 
maximum pain is found at the point of traction it- 
self. In the first case, the cicatrix should be re- 
moved and the neuroma found; in the second case, 
the muscle should be incised and a neurotomy per- 
formed, with resection of the nerve. To avoid the 
two accidents, the author recalls Farabeuf's saying: 
"Resect the nerves above the cutaneous surfaces 
and protect the nerve from bony contact." Bac- 
teriologically speaking, neuromas are absolutely 
sterile. 

Reamputations are required in cases of too short 
a flap, ulceration, neurotic pains, osteomyelitis, 
or sequestras. One must resect in situ, the strictest 
care being necessary, freeing carefully all sclerotic 
regions. To avoid the alarming frequency of 
sepsis, the use of good drainage is recommended, 
and a redressing of the wound at the least sign of 
infection. All these regions are in a state of latent 
microbism, or in a medium favorable to infection; 
traumatism awakens and diffuses the virulence. 
The pathogenesis of ankylosis, as known, is due to an 
infectious process having reached the articulation. 
In the great majority of cases it is due to faulty 
treatment. Early mobilization of the amputated 
members and the use of English suspension ap- 
paratus are clearly justifiable. The author recom- 
mends that surgeons pay closer attention to the 
articulation adjacent to an amputation. For the 
leg, the knee should be maintained in a rectilinear 
position, as often and as long as possible. For the 
shoulder, the movements should be practiced before 
the stump cicatrizes. 

Practical conclusions for each variety of ampu- 
tation are: 

A hip amputation should be made as low as pos- 
sible, the length of the arm of leverage being of 
prime importance, especially in the upper third of 
the femur. A stump of 10 cm. is the minimum 
required to give a good field for applying the new 
prosthetic apparatus, a femoral lever that should be 
efficacious. To obtain a good product it is necessary 
to have a femur 14 to 1 5 cm. long. 

A sub- or intratrochanteric amputation, or the 
upper fourth of the femur, is harder to fit with an 
apparatus than a hip dislocation and gives the same 
functional results: the amputated walk on the pelvis. 
It should not be abandoned, for it is less dangerous 
than a coxofemoral dislocation. To diminish the 
inconvenience the femur should be straightened as 
much as possible during the healing of the wound. 



GENERAL SURGERY — SURGERY OF THE EXTREMITIES 



151 



Amputations by the circular method give terminal 
cicatrices which have all the defects of seat, form, 
and adherence; the technique requires further per- 
fecting. 

An anterior flap or a combination of two flaps 
are the procedures of choice. These require a higher 
incision of the bone and therefore leave a shorter 
stump, a disadvantage which the circular method 
lacks; however, the flap method should be preferred 
wherever the higher bone section necessary does not 
permit the stump of a medium type to surpass one 
of a higher type, nor one of an inferior type that of a 
medium type. 

One should further direct carefully the process of 
cicatrization by the drawing nearer and the me- 
thodic traction of the flaps. Intracondyloid am- 
putations of the femur have given good results to 
Gourdon, ^stor, Desfosses, and the author. They 
permit the patient, with a good anterior flap, to carry 
the body weight on the extremity of the stump and 
to walk remarkably well. In all hip amputations, 
the author emphasizes the necessity of high section- 
ing of the sciatic nerve and the particular care of the 
rough line. 

According to Desfosses, a former pupil of the 
author and now surgeon of the orthopedic center 
at Clermont-Ferraud, after the fixation of the 
patella under the femur and the suture of the 
patellar tendon to the anterior fibrous regions, 
knee amputation with condyloid resection and su- 
ture of the patella (Gritti's operation) to the 
posterior hip muscles gives excellent results. 

Knee dislocations proper, with or without the 
conservation of the patella, give generally unfavor- 
able results. Dissection performed by the author 
in three cases of reamputation showed the skin 
closely adherent to the atrophied cartilages, with- 
out any sliding. This causes the original pain, and 
this is the certain consequence of suppuration. It is 
preferable, therefore, to perform an intracondyloid 
amputation. 

Leg amputations immediately below the articu- 
lation (an excellent operation) give good general 
results. It seems that the skin provided with the 
patella supports constantly, perfectly, and indefi- 
nitely the body weight, when the adherent con- 
dyles crush it against the apparatus. The difference 
in results is due probably to post-operative infec- 
tion causing adhesions, and not to the skin of the 
condyloid cartilage. Leg amputations should give 
a cicatrix that will allow for a point of support on the 
stump directly or on the tibial notches, and should 
be performed as low as possible. The experiences 
in the present war show that an external flap gives 
acceptable cicatrices, while the circular method 
furnishes results generally deplorable; a number of 
such stumps cannot be fitted with artificial limbs, 
and they require one or two reamputations. The 
present operative procedure should be modified at 
the seat as well as in the cutting of the flaps. Chas- 
saignac says that "the place of election is the one of 
exclusion"; therefore, the place to be selected, if 





Fig. 3. Radiography of an amputated leg stump show- 
ing an osteitis of the anterior tuberosity of the tibia. 



one exists, should be the bony section at the lowest 
.point which will permit the cutting of a good flap. 
The posterior flap is preferable, and although it 
may leave a stump a little too large it can be re- 
duced by compression. The author thinks that 
bones are badly cut in leg amputations. He 
possesses dozens of radiographs showing the fibula 
sectioned much too low, far under the tibia. He 
recommends high sectioning of the fibula. When 
the amputation is to be done near the knee, less 
than 8 cm. from the joint, it would be better to 
cut the bones higher than lower. The very high 
cutting even in the tuberosity of the tibia gives 
excellent results and the author recommends its 
use. In all these amputations, it is advisable to 
provide for the perfect mobility of the knee, and to 
direct the cicatrization of the soft parts by elastic 
molds or by traction. 

Tibiotarsal disarticulation, with the cutting of 
the malleoli, as well as the intramalleolar amputation, 
gives good results. Subastragalus disarticulation, 
the osteoplastic amputation of the calcaneus, and 
the Syme operation are recommended. With 
these operations the fitting with artificial appHances 
is easy and the stump is tolerant. 



152 



INTERNATIONAL ABSTRACT OF SURGERY 



To remedy an amputation, so-called, of Chopart, 
when the tibiotarsal articulation is placed in flexion 
and the head of the astragalus carried down and the 
cicatrix becomes exposed instead of protected, the 
author had to perform two astragalectomies with 
calcaneal osteoplasty. In war surgery, when sup- 
puration is the rule, the Chopart operation is to be 
discarded, for to finish it by an arthrosis, fixing the 
tibiotarsal joint, or to require a particular surveil- 
lance of the cicatrization and its sequelae, is by no 
means practical. Radiographs show that in many 
so-called Chopart operations, the scaphoid has 
been forgotten. Lisfranc's amputation and its 
analogous operations are unanimously recognized. 
They give good stumps on which the patient with 
an orthopedic shoe can walk very easily, even 
gracefully. The author has seen a great number of 
such cases due to frozen feet. For an upper limb 
the result of amputations and setting for disloca- 
tions are infinitely more satisfactory than for a 
lower limb. Only 50 per cent of the cicatrices were 
found vicious. Amputation as far as possible from 
the member's root should be an absolute rule. 

For the hand, the smallest stump, including but 
the thenar eminence and a portion of the metacar- 
pal bones, gives services infinitely greater than the 
most perfect artificial hand that may be substituted. 
A dorsal cicatrix is the most preferable for the 
prosthesis. 

For the wrist, the palmar flap gives an excellent 
stump. Circular amputations result in a painful 
cicatrix, unable to support the pressure. 

As to the forearm, the author emphasizes that an 
amputation too close to the elbow does not make 
allowance for the attachment of an apparatus for 
flexion. It is therefore profitable to gain a few centi- 
meters which increase the value of the member 
50 per cent. The circular method or the flap 
method give good results, provided the cicatrix is 
pliable and free; a condition which is not common. 
Especial stress should be placed upon the site 
selected for amputation, for the patient should 
have the benefit of all movements of flexion and 
extension. New apparatus help to conserve move- 
ments of pronation and supination. It is further 
advised that during the entire period of cicatrization 
the mobility of the elbow and that of the radio- 
cubital articulation be carefully watched. The 
author has seen a number of cases of articular stifT- 
ness, irreducible. 

For the arm, the saving of the head of the hu- 
merus, if possible, is to be preferred to a complete 
disarticulation. 

From a functional point of view, the very short 
stumps, less than four fingers in width, are of no 
use and the prosthesis can furnish an arm for ap- 
pearances only. Subjacent amputations allow 
the wearing of an apparatus whose practicabihty 
depends upon the mobility of the joint, and cases 
of ankylosis of that joint are too numerous. 

The author is opposed to the practice of excessive 
removal of constrictions or deep cauterizations, too 



close and destructive, which have been banished, 
fortunately, by all ambulances at the front. 

Raoul L. Vioran. 

Openshaw, T. H.: Amputations; Their Prevention 
and After-treatment. Practitioner, Lond., 1016 
xcvi, 284. ' 

From the author's personal experience with am- 
putations, he estimates that amputations have in- 
creased seven-fold since the beginning of the war 
over what they ordinarily are in England. Am- 
putations ought to be considered from the view- 
point of the practicability of fitting an artificial 
limb to the stump afterward. The author thinks 
that amputations may be avoided in great measure: 
(i) by absolute rest with sufficient splinting; (2) 
the application of extension or fixing the limb in 
plaster of Paris from the first; (3) frequent antiseptic 
dressings; and (4) free drainage. He considers 
that the aseptic dressing is useless in war surgery and 
that dependence should be placed on antiseptic dress- 
ings. In general the circular method of amputa- 
tion is the best in case of gas gangrene or septicaemia. 
Much time, however, is gained and the healing of 
the wound shortened if the flaps are so cut that they 
can be approximated when drainage ceases. Em- 
phasis is laid on the fact that during amputation the 
nerves encountered must be cut high up in order to 
avoid a consequent neuroma of the nerve-stump. 

Amputation at the hip-joint is best performed by 
first ligating the femoral vessels, disarticulating the 
hip, and then finishing the amputation. This type 
of operation gives a triangular scar and the stump is 
readily fitted to an artificial leg. A long flabby 
stump is here a great nuisance, as it cannot rest 
solidly on the cut of the artificial limb which re- 
ceives it. In amputations through the thigh, any 
shaped flaps may be used so long as the bone is well 
covered. The longer the piece of bone which is left, 
the more assistance will it be to the patient in 
managing his artificial leg. The author recom- 
mends Carden's method in transcondylar amputa- 
tions. In this the knee-cap is resected and the long 
flap is made anteriorly so that the scar comes to 
lie at the back of the leg. In amputations through 
the knee-joint the author uses the method of Stephen 
Smith, in which two lateral flaps are made and the 
cartilages of the knee-joint and the patella are left. 
Operation below the knee is best done at the seat 
of election. The tibial stump may be only i inch 
or as much as 5 inches in length. It is of no ad- 
vantage to have it longer than this. Either type 
of flap may be used, lateral or posterior. For 
practical usefulness to the patient, he advocates 
amputation at the point of election where there is 
any question of amputation in the region of the ankle 
because of the more satisfactory use that the 
patient can make with this type of stump. 

In amputation wounds healing by first intention, 
the stump can be fitted to an artificial leg in about 
six weeks. Care must be taken, however, to see 



GENERAL SURGERY — SURGERY OF THE EXTREMITIES 



153 



that the stump has shrunk to its final size before an 
accurate adjustment can be definitely made. 
The conditions which will prevent an artificial leg 
from being fitted may be enumerated as follows: 

1. Painful bulbous nerves. 

2. Necrosis of the bone. 

3. Sinus leading to bone or foreign body. 

4. Inflammation. 

5. Dense, adherent, or eczematous scars. 

6. Ulceration. 

7. Loose or flabby stump, or too fat a stump. 

8. Contracted limb. 

He advocates the applying of splints in all ampu- 
tations done at the seat of election in order to pre- 
vent contraction of the knee. In case such should 
happen, it will be necessary to do a tenotomy on 
the hamstrings, and in case this does not suffice, to 
cut the posterior ligament in the knee. The au- 
thor thinks that the shrinking of this ligament is to 
blame for contraction of the knee after amputation. 
The artificial leg should be fitted with a pelvic band 
when the amputation has been at or above the mid- 
dle of the thigh, in order to prevent the leg rotating 
in or out. Casts of the stump, from which the cup 
receiving it in the artificial leg is moulded, should 
be made with the patient bearing his weight upon the 
stump. 

In the upper extremity, it is necessary to leave 
every single portion which is possible. This is 
especially important in the hand. Even one finger 
or a thumb which can flex is better than any 
artificial appliance. The carpus should be left 
whenever possible, for this enables an artificial hand 
to be articulated. When the amputation has been 
above the elbow-joint, the author believes that the 
arm invented by Karns, of Warren, Penn., will 
prove by far the most serviceable. The best stump 
for this arm is that resulting from amputation at the 
middle of the humerus down to two inches from the 
wrist-joint. Harry G. Sloan. 

Packard, R. G. : Functional Result of Astragalec- 
tomy in Infantile Paralysis. Colo. Med., 1916, 
xiii, 93. 

The author's report is based upon cases observed 
in the Boston Children's Hospital during the five- 
year period from 1909 to 1913 inclusive. The 
time elapsing between the attack and operation 
varied from two to eleven years. The deformities 
of the feet varied greatly and there was often an 
accompanying paralysis of the muscles of the cor- 
responding leg and thigh. 

The operation originally advocated by Whitman 
but modified slightly consists essentially in the com- 
plete excision of the astragalus, more easily in three 
portions, and the backward displacement of the 
foot in such a way that the external malleolus may 
cover the calcaneocuboid joint, and the internal 
malleolus may be forced into the depression behind 
the scaphoid. The foot is then held in moderate 
equinus and the whole limb fixed in plaster of Paris 
for four to six months. 



The aims of the operation are: (i) to secure lat- 
eral stability; (2) to obtain a better anteroposterior 
balance; (3) to overcome shortening of the foot; and 
(4) to overcome ankylosis by performing the opera- 
tion subperiosteally. 

In the 16 cases lateral stability was secured in a 
considerable degree in every case. The functional 
deformities were very well corrected. In the cor- 
rection of the foot-drop the results were not quite 
so good. The arcs of passive movement varied 
from 10 to 70°. The operated feet measured o to 
1.25 inches shorter than their mates and i to 4 inches 
shallower. The functional results of the operated 
feet were excellent in 4, good in 6, and fair in 6. 

In every case where it was possible to interview 
them, the parents made the statement that the 
children showed more eflacient control of the ex- 
tremity than before the operation. Philip Lewin. 

ORTHOPEDICS IN GENERAL 

McKenzie, B. E. : Treatment of Club-Foot. Canad. 
J. Med. b' Surg., 1916, xxxix, 121. 

The author describes the pathological anatomy of 
club-foot, laying emphasis on the contractures of the 
various tendons and on the three elements of the 
compound deformity, equinus, varus, and supina- 
tion of the foot. He advocates a two-stage pro- 
cedure, the first being the correction of the varus 
and the supination elements by means of manipula- 
tion on a wedge-shaped block with retention in 
plaster. If necessary a subcutaneous tenotomy of 
' the plantar fascia is done. The second stage is the 
correction of the equinus, and if necessary a tenot- 
omy of the tendo achillis is performed. If the 
latter is done in the first stage it interferes greatly 
with the correction of the varus. The time re- 
quired varies from six weeks to three months for 
the whole procedure. 

McKenzie deprecates operative work and re- 
tention in any form of dressing in children under 
one year of age and instead advises manipulation, 
with emphasis on the correction of the varus part 
of the deformity. In not more than 5 per cent of 
children and 10 per cent of adults is any operation 
necessary and then only a wedge of bone is removed 
from the outer aspect of the astragalus. All in- 
cisions opening up and leaving a gap on the inner 
surface of the foot are condemned. The neglect 
of a proper shoe and a proper night brace is also 
censured. If complete correction has been made 
and a proper shoe worn there is no need of a day 
brace. Open incisions to cut tendons or fasciae 
are not necessary. R. S. Bromer. 

Willard, D. P.: Subastragalar Arthrodesis in 
Lateral Deformity of Paralytic Feet. Tr. 

Am. Orth. Ass., Washington, 1916, May. 

Lateral deformity of the feet in infantile paralysis 
occurs in the astragaloscaphoid and the astragalo- 
calcaneal joints and not in the ankle. Arthrodesis 
of these subastragalar joints gives a stable foot for 



154 



INTERNATIONAL ABSTRACT OF SURGERY 



weight-bearing, does not interfere with ankle motion, 
does not shorten the leg, and gives a rigid point of 
attachment for the unparalyzed muscles. In this 
operation there is no careful dissection of the joint 
surfaces, instead there is a rough digging and 
gouging of the articular areas and the bony surfaces 
between them with no attempt to remove the frag- 
ments that are torn loose. Proper fixation of the 
foot in the proper position after operation is es- 
sential. The patient is allowed to walk in a cast at 
the end of four weeks, and the cast is removed in 
eight weeks. The operation has been successfully 
done in six-year-old children. It can be well com- 
bined with tendon-transplantation. A report of 
cases by the author is given. 

Brian, B.: Talipes Equinus Through Myositis of 
the Triceps (Pie bot equine per miositis del 
triceps sural). Prensa med., Argent., 1916 ii, 354. 

The causes which keep the foot in the equinus 
position are the retraction of the tendo achillis 
and the malformation of the astragalus. 

The retraction and shortening of the tendo 
achillis was the cause in the case reported by the 
author in a boy of 17 ; this kept the foot in a definite 
position. The surgical indication was therefore 
apparent, lengthening of the tendon. 

The osseous lesions were secondary: flexion of the 
foot, disappearance of the astragaloid function, and 
inflection of the ankle. Astragalectomy was in- 
dicated for the correction. Radiology six months 
after intervention showed firm overriding on the 
superior face of the os calcis, also the neo-arthrosis 
which is formed and which permits passive and 
active movement of flexion and extension through 
an angle of 20°. The plantar impression taken since 
operation shows the contour of the foot to be normal. 

W. A. Brennan. 

Young, J. K. : The Etiology of Congenital Absence * 
of Parts. Lancet-Clin., 1916, cxv, 248. 

The author gives some facts bearing on the 
etiology and pathology of these conditions, some 
of which he thinks are amenable to treatment. 

A case is cited showing various absences of bones 
and digits and other marked deformities. He 
rather adheres to the so-called "ray" theory because 
in this case all of the parts supplied by the rays 
from a common center were affected. He has also 
given some favorable consideration to the amniotitis 
theory where the adhesive band cut off the parts. 
It is shown that the congenital absence of both 
upper and lower extremities is rare, and the humerus 
is most rarely absent while the radius is most 
frequently found absent. The theories most 
plausible are: 

1 . The theory of heredity. 

2. Prenatal disease (musculonervous theory). 

3. Arrest of development (osseous theory). 

4. Mechanical pressure (intra-uterine theory). 

5. Amniotic adhesion theory. 

His conclusions are that most of the theories are 



faulty, illogical, and unsupportable and that most 
of the congenital absences are due to adhesive bands, 
and amniotitis being the cause of this and trau- 
matism being the cause of amniotitis gives a fair 
basis for his hypothesis. H. W. Maltby. 

Henderson, M.S.: The Intraperitoneal Inoculation 
of Animals; Its Diagnostic Value in Orthopedic 
Surgery. Tr. Am. Orth. Ass., Washington, 1916, 
May. 

The difficulty and uncertainty of the diagnosis in 
obscure joint lesions may be very materially les- 
sened by employing the simple test of intraperitoneal 
inoculation of animals, which has been a routine 
procedure in the orthopedic section of the Mayo 
Clinic during the last three years in suspected cases 
of tuberculosis. The results have emphasized the 
fact that the symptoms produced by tuberculosis of 
a joint may be very mild. The test has allowed a 
differentiation in many instances between a diagno- 
sis of infectious arthritis and tuberculosis, which 
could not have been made with certainty by any 
other method. For this reason it would seem that 
it may be more readily employed when it is possible 
to obtain fluid or material for the test. 

Of 143 patients furnishing material there were 40 
who gave a positive test. The test is considered 
positive when miliary abdominal tuberculosis is 
demonstrated at necropsy of the animal (guinea 
pigs in this series). By cutting into the spleen and 
spreading the material from a tubercle on a glass 
slide, the acid-fast bacilli can be demonstrated by the 
ordinary carbolfuchsin stain. A somewhat high per- 
centage of negative results in this series of suspected 
cases can be to a large extent accounted for by the 
fact that in the early part of the work antiformin 
was used to rid the fluid or tissue of mixed infection. 
This solution acts on the tubercle bacilli either to 
kill or reduce their virulence, and thus the low re- 
sistance of the guinea pig is sufficient to overcome 
them. Since the antiformin solution greatly re- 
duces the value of the test, it should not be used. 

Baetjer, F. H. : Relation of Visceroptosis to Spinal 
Lesions. Tr. Am. Orth. Ass., Washington, 1916, 
May. 

In dealing with the subject the author has classi- 
fied the position of the gastro-intestinal tract ac- 
cording to the build of the individual. He sub- 
divides the position of the gastro-intestinal tract 
into three divisions: First, in individuals weighing 
150 pounds or more, the stomach is always high up 
in the abdomen, occupying a transverse position; 
the pylorus and duodenum lying to the right of the 
median line and well up under the gall-bladder 
region. The transverse colon is also well up, lying 
just beneath the stomach. Second, where the 
individual weighs in the neighborhood of 1 20 pounds, 
the stomach is cowhorn in shape, the greater curva- 
ture lying at, or just below, the umbilicus and pylorus 
and duodenum either in the midline or just to the 



GENERAL SURGERY — SURGERY OF THE SPINAL COLUMN AND CORD 155 



right. The transverse colon is slightly prolapsed, 
lying about two inches above the crest of the ilium. 
Third, where the individual weighs around no 
pounds, the stomach is of the fishhook variety, the 
fundus always in the pelvis, lying completely to the 
left of the midline. The transverse colon is away 
down in the pelvis. 

The author then goes on to show that all of these 
positions may be perfectly normal, the important 
thing being whether or not the stomach functions 



properly; in other words, as long as the gastro- 
intestinal tract functions normally the position does 
not matter. 

In analysis of cases in the three classes, the 
author could trace no connection at all between any 
spinal twists and strains with the position of the 
gastro-intestinal tract. The congenital abnormality 
of the spine did not seem to be confined to any one 
class, but occurred just as frequently in all of the three 
classes. 



SURGERY OF THE SPINAL COLUMN AND CORD 



Sever, J. W. : Fracture of the Lumbar Vertebrae 
and the Transverse Processes; a Report of 
Four Additional Cases. Boston M. &" S. J., 1916, 
cLxxiv, 606. 

Sever adds 4 new cases to his previous 7, all due 
to severe trauma and all diagnosed with the aid of 
the X-ray. The cases involve: (i) the twelfth 
dorsal, first and fourth lumbar; (2) the first lumbar; 
(3) twelfth dorsal, first and second lumbar; (4) a 
transverse process of four lumbar vertebrae besides 
the disarticulation of the last rib on the same side. 
All these cases were without nerve involvement and 
all will probably improve with ordinary orthopedic 
treatment. F. C. Kh)ner. 

Peckham, F. E.: Scoliosis. Tr. Am. Orth. Ass., 
Washington, 1916, May. 

The author discusses the true etiology of scoliosis; 
i.e., the diseases or conditions which produce a 
softening of the bones and soft structures. Some of 
these diseases and conditions are: hypothyroidism, 
rhachitis, infectious diseases including the toxic 
diseases (auto), rapid growth, and possibly others. 
The spinal column as an entity supports the body 
weight; i.e., the head and trunk. With the bones 
softened and the ligaments lax, this support yields 
under the superincumbent body weight. The spine 
settles and is thus pushed downward into a scoliotic 
deformity. This is the anatomico-physiological ex- 
planation of the mechanics of deformity formation 
based upon these etiological factors. One case of 
hypothyroidism is reported treated by the adminis- 
tration of thyroid extract. 

For the mechanical treatment a frame is described 
on which the patient is placed with the body flexed 
and lying face down. Lateral and rotary pulls are 
then applied to the spine. Extension on both the 
head and feet may also be added. In this way the 
spine may be straightened and a plaster jacket ap- 
plied. A case is reported showing the improvement 
obtained under such treatment. Treatment based 
on the etiology is urged in addition to the me- 
chanical methods. 

This paper is only a preliminary report. 



Hammond, R.: Certain Aspects of Injuries of the 
Lower Spine. Tr. Am. Orth. Ass., Washington, 
1916, May. 

These cases are roughly classified as (i) those with 
actiial bone injury, such as fracture of the body, 
transverse process, or spinous process of a vertebra, 
often associated with a partial luxation of one verte- 
bra on another, or the slipping of an intervertebral 
disc; (2) cases of severe wrenching or strain, due to 
partial or complete rupture of ligaments, relaxation 
of the sacro-iliac or lumbosacral joints, and associated 
with periarthritis, periostitis, and myositis of the 
structures involved. Only the second class is con- 
sidered in this paper. Certain anatomical types of 
spine are more easily disposed to injury than others. 
Accurate diagnosis is difiicult, and the X-ray is 
inadequate in this particular type of back injury 
where fracture or similar injury is not demon- 
strable. These cases are prone to invalidism, 
are generally not malingerers, and do not respond 
readily to treatment. One of the trying features 
is the chronicity of these cases, with attendant 
mental unrest, which serves to prolong the convales- 
cence. Social workers are of much aid to the physi- 
cian in following up these cases and inducing them 
to return for treatment after they have become dis- 
couraged. 

Carderelli, A.: Cervical Spondylitis of Doubtful 
Nature (Spondilite cervicale di dubbia natura). 
Riforma med., 1916, xxxii, 157. 

The author draws attention to a variety of spon- 
dylitis with a syndrome which must not be con- 
founded with that described by Struempell and 
Marie under the name of rhisomelic spondylitis. 
In this latter disease there is a total ankylosis of the 
vertebral column and also of the large articulations 
in the vicinity of the vertebral column. The 
spinal medulla is not usually involved; neither are 
the smaller articulations affected. 

The spondylitis now referred to has character- 
istics of its own. It begins with cervical pain, or 
perhaps the pain is sometimes in a part of the verte- 
bral column other than the neck. The pain is very 
violent not permitting the least movement, whereas 



156 



INTERNATIONAL ABSTRACT OF SURGERY 



in ankylosis of the column rigidity does not cause 
any pain to the patient. The pain usually radiates 
into other regions or into the upper and lower limbs 
according to the part of the column affected. The 
spinal medulla is also usually involved, and there 
is a slight or even a complete paralysis which may 
be flaccid or spastic. 

This form of spondylitis generally results from 
rheumatism, tuberculosis, or gout and usually yields 
to treatment while the malady described by Struem- 
pell and Marie, the cause of which is not known, is 
incurable. W. A. Brennan. 



Le Breton, P. : A Case of Fracture of the Odontoid 
Process of the Axis. Tr. Am. Orth. Ass., Wash- 
ington, 19 16, May. 

The patient, a young man, received a severe con- 
tusion of the head and right side of the neck, caused 
by a horse rolling back on him. The symptoms 
were severe pain, rigidity of the neck, a "wry neck" 
position with the head to the left. Paralysis was 
absent. The spin